NRS 695C.163 Eligibility
for coverage: Effect of eligibility for medical assistance under Medicaid; assignment
of rights to state agency.

NRS 695C.165 Eligibility
for coverage: Organization prohibited from asserting certain grounds to deny
enrollment of child pursuant to order if parent is enrolled in health care
plan.

NRS 695C.167 Eligibility
for coverage: Certain accommodations to be made when child is covered under
health care plan of noncustodial parent.

NRS 695C.169 Eligibility
for coverage: Organization to authorize enrollment of child of parent who is
required by order to provide medical coverage under certain circumstances;
termination of coverage of child.

NRS 695C.020Legislative declaration.The
Legislature hereby declares that the rising cost of health services in recent
years has led government agencies, private organizations, and legislative
bodies to seek alternatives to the traditional medical delivery system which
would provide improved health care and would provide such health care at a
lower cost. The health maintenance organization is a concept which has received
much attention as one means through which an improvement in delivery might be
achieved. The Legislature therefore enacts this chapter to carry out this
objective.

(Added to NRS by 1973, 1246)

NRS 695C.030Definitions.As
used in this chapter, unless the context otherwise requires:

1. “Comprehensive health care services”
means medical services, dentistry, drugs, psychiatric and optometric and all
other care necessary for the delivery of services to the consumer.

2. “Enrollee” means a natural person who
has been voluntarily enrolled in a health care plan.

3. “Evidence of coverage” means any
certificate, agreement or contract issued to an enrollee setting forth the
coverage to which the enrollee is entitled.

4. “Health care plan” means any
arrangement whereby any person undertakes to provide, arrange for, pay for or
reimburse any part of the cost of any health care services and at least part of
the arrangement consists of arranging for or the provision of health care
services paid for by or on behalf of the enrollee on a periodic prepaid basis.

5. “Health care services” means any
services included in the furnishing to any natural person of medical or dental
care or hospitalization or incident to the furnishing of such care or
hospitalization, as well as the furnishing to any person of any other services
for the purpose of preventing, alleviating, curing or healing human illness or
injury.

6. “Health maintenance organization” means
any person which provides or arranges for provision of a health care service or
services and is responsible for the availability and accessibility of such
service or services to its enrollees, which services are paid for or on behalf
of the enrollees on a periodic prepaid basis without regard to the dates health
services are rendered and without regard to the extent of services actually
furnished to the enrollees, except that supplementing the fixed prepayments by
nominal additional payments for services in accordance with regulations adopted
by the Commissioner shall not be deemed to render the arrangement not to be on
a prepaid basis. A health maintenance organization, in addition to offering
health care services, may offer indemnity or service benefits provided through
insurers or otherwise.

7. “Provider” means any physician,
hospital or other person who is licensed or otherwise authorized in this state
to furnish health care services.

NRS 695C.050Applicability of certain provisions. [Effective through December
31, 2013.]

1. Except as otherwise provided in this
chapter or in specific provisions of this title, the provisions of this title
are not applicable to any health maintenance organization granted a certificate
of authority under this chapter. This provision does not apply to an insurer
licensed and regulated pursuant to this title except with respect to its
activities as a health maintenance organization authorized and regulated
pursuant to this chapter.

2. Solicitation of enrollees by a health
maintenance organization granted a certificate of authority, or its
representatives, must not be construed to violate any provision of law relating
to solicitation or advertising by practitioners of a healing art.

3. Any health maintenance organization
authorized under this chapter shall not be deemed to be practicing medicine and
is exempt from the provisions of chapter 630
of NRS.

4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.173,
inclusive, 695C.1733 to 695C.200,
inclusive, 695C.250 and 695C.265
do not apply to a health maintenance organization that provides health care
services through managed care to recipients of Medicaid under the State Plan
for Medicaid or insurance pursuant to the Children’s Health Insurance Program
pursuant to a contract with the Division of Health Care Financing and Policy of
the Department of Health and Human Services. This subsection does not exempt a
health maintenance organization from any provision of this chapter for services
provided pursuant to any other contract.

5. The provisions of NRS 695C.1694, 695C.1695
and 695C.1731 apply to a health maintenance
organization that provides health care services through managed care to
recipients of Medicaid under the State Plan for Medicaid.

1. Except as otherwise provided in this
chapter or in specific provisions of this title, the provisions of this title
are not applicable to any health maintenance organization granted a certificate
of authority under this chapter. This provision does not apply to an insurer
licensed and regulated pursuant to this title except with respect to its
activities as a health maintenance organization authorized and regulated
pursuant to this chapter.

2. Solicitation of enrollees by a health
maintenance organization granted a certificate of authority, or its
representatives, must not be construed to violate any provision of law relating
to solicitation or advertising by practitioners of a healing art.

3. Any health maintenance organization
authorized under this chapter shall not be deemed to be practicing medicine and
is exempt from the provisions of chapter 630
of NRS.

4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.173,
inclusive, 695C.1733 to 695C.200,
inclusive, and 695C.265 do not apply to a health
maintenance organization that provides health care services through managed
care to recipients of Medicaid under the State Plan for Medicaid or insurance
pursuant to the Children’s Health Insurance Program pursuant to a contract with
the Division of Health Care Financing and Policy of the Department of Health
and Human Services. This subsection does not exempt a health maintenance
organization from any provision of this chapter for services provided pursuant
to any other contract.

5. The provisions of NRS 695C.1694, 695C.1695
and 695C.1731 apply to a health maintenance
organization that provides health care services through managed care to
recipients of Medicaid under the State Plan for Medicaid.

2. For the purposes of subsection 1, unless
the context requires that a provision apply only to insurers, any reference in
those sections to “insurer” must be replaced by “health maintenance
organization.”

2. For the purposes of subsection 1,
unless the context requires that a provision apply only to insurers, any reference
in those sections to “insurer” must be replaced by “health maintenance
organization.”

2. For the purposes of subsection 1,
unless the context requires that a provision apply only to a group health plan
or a carrier that provides coverage under a group health plan, any reference in
those sections to “group health plan” or “carrier” must be replaced by “health
maintenance organization.”

2. For the purposes of subsection 1,
unless the context requires that a provision apply only to a group health plan
or a carrier that provides coverage under a group health plan, any reference in
those sections to “group health plan” or “carrier” must be replaced by “health
maintenance organization.”

1. Any person may apply to the
Commissioner for and obtain a certificate of authority to establish and operate
a health maintenance organization in compliance with this chapter. No person
shall operate a health maintenance organization without obtaining a certificate
of authority under this chapter. A foreign corporation may qualify under this
chapter, subject to its qualification to do business in this state as a foreign
corporation.

2. No person shall be certified to
establish or operate a health maintenance organization in this state, nor sell
or offer to sell, or solicit offers to purchase or receive advance or periodic
consideration in conjunction with health care plans unless such health
maintenance organization provides or arranges for the provision of
comprehensive health care services.

3. Every health maintenance organization
or person operating a health maintenance organization shall submit an
application for a certificate of authority under NRS
695C.070 within 30 days after July 1, 1973. Each such applicant may
continue to operate until the Commissioner acts upon the application. In the
event that an application is denied under NRS 695C.090
and 695C.100, the applicant shall thereafter be
treated as a health maintenance organization whose certificate of authority has
been revoked. For purposes of this subsection, a health maintenance organization
shall be deemed to be in operation only if health care services are being
provided to the public generally or to some group or groups thereof.

(Added to NRS by 1973, 1247)

NRS 695C.070Certificate of authority: Application.Each
application for a certificate of authority must be verified by an officer or
authorized representative of the applicant, must be in a form prescribed by the
Commissioner, and must set forth or be accompanied by the following:

1. A copy of the basic organizational
document, if any, of the applicant, and all amendments thereto;

2. A copy of the bylaws, rules or
regulations, or a similar document, if any, regulating the conduct of the
internal affairs of the applicant;

3. A list of the names, addresses and
official positions of the persons who will be responsible for the conduct of
the affairs of the applicant, including all members of the board of directors,
board of trustees, executive committee, or other governing board or committee,
the officers in the case of a corporation, and the partners or members in the
case of a partnership or association;

4. A copy of any contract made or to be
made between any providers or persons listed in subsection 3 and the applicant;

5. A statement generally describing the
health maintenance organization, its health care plan or plans, the location of
facilities at which health care services will be regularly available to
enrollees and the type of health care personnel who will provide the health
care services;

6. A copy of the form of evidence of
coverage to be issued to the enrollees;

7. A copy of the form of the group
contract, if any, which is to be issued to employers, unions, trustees or other
organizations;

9. The proposed method of marketing the
plan, a financial plan which includes a 3-year projection of the initial
operating results anticipated and the sources of working capital and any other
sources of funding;

10. A power of attorney, executed by the
applicant, appointing the Commissioner and the authorized deputies of the
Commissioner as the true and lawful attorney of such applicant in and for this
State upon whom all lawful process in any legal action or proceeding against
the health maintenance organization on a cause of action arising in this State
may be served;

11. A statement reasonably describing the
geographic area to be served;

12. A description of the procedures for
resolving complaints and procedures for external reviews to be used as required
under NRS 695C.260;

13. A description of the procedures and
programs to be implemented to meet the quality of health care requirements in NRS 695C.080;

14. A description of the mechanism by
which enrollees will be afforded an opportunity to participate in matters of
program content under subsection 2 of NRS 695C.110;
and

15. Such other information as the
Commissioner may require to make the determinations required in NRS 695C.080.

NRS 695C.080Certificate of authority: Evaluation of application. [Effective
through December 31, 2013.]

1. Upon receipt of an application for
issuance of a certificate of authority, the Commissioner shall forthwith
transmit copies of such application and accompanying documents to the State
Board of Health.

2. The State Board of Health shall
determine whether the applicant for a certificate of authority, with respect to
health care services to be furnished:

(a) Has demonstrated the willingness and ability
to ensure that such health care services will be provided in a manner to ensure
both availability and accessibility of adequate personnel and facilities and in
a manner enhancing availability, accessibility and continuity of service;

(b) Has organizational arrangements, established
in accordance with regulations promulgated by the State Board of Health; and

(c) Has a procedure established in accordance
with regulations of the State Board of Health to develop, compile, evaluate and
report statistics relating to the cost of its operations, the pattern of
utilization of its services, the availability and accessibility of its services
and such other matters as may be reasonably required by the State Board of
Health.

3. Within 90 days of receipt of the application
for issuance of a certificate of authority, the State Board of Health shall
certify to the Commissioner whether the proposed health maintenance
organization meets the requirements of subsection 2. If the State Board of
Health certifies that the health maintenance organization does not meet such
requirements, it shall specify in what respects it is deficient.

1. The Commissioner shall determine
whether the applicant for a certificate of authority, with respect to health
care services to be furnished:

(a) Has demonstrated the willingness and ability
to ensure that such health care services will be provided in a manner to ensure
both availability and accessibility of adequate personnel and facilities and in
a manner enhancing availability, accessibility and continuity of service;

(b) Has organizational arrangements, established
in accordance with regulations promulgated by the Commissioner and in
consultation with the State Board of Health; and

(c) Has a procedure established in accordance
with regulations of the Commissioner to develop, compile, evaluate and report
statistics relating to the cost of its operations, the pattern of utilization
of its services, the availability and accessibility of its services and such
other matters as may be reasonably required by the Commissioner.

2. Within 90 days of receipt of the
application for issuance of a certificate of authority, the Commissioner shall
certify whether the proposed health maintenance organization meets the
requirements of subsection 1. If the Commissioner certifies that the health
maintenance organization does not meet such requirements, it shall specify in
what respects it is deficient.

NRS 695C.090Certificate of authority: Issuance. [Effective through December
31, 2013.]The Commissioner shall
issue or deny a certificate of authority to any person filing an application
pursuant to NRS 695C.060 within 90 days of receipt
of the certification from the State Board of Health. Issuance of a certificate
of authority must be granted upon payment of the fees prescribed in NRS 695C.230 if the Commissioner is satisfied that
the following conditions are met:

1. The persons responsible for the conduct
of the affairs of the applicant are competent, trustworthy and possess good
reputations.

2. The State Board of Health certifies, in
accordance with NRS 695C.080, that the health
maintenance organization’s proposed plan of operation meets the requirements of
subsection 2 of NRS 695C.080.

3. The health care plan furnishes comprehensive
health care services.

4. The health maintenance organization is
financially responsible and may reasonably be expected to meet its obligations
to enrollees and prospective enrollees. In making this determination, the
Commissioner may consider:

(a) The financial soundness of the health care
plan’s arrangements for health care services and the schedule of charges used
in connection therewith;

(b) The adequacy of working capital;

(c) Any agreement with an insurer, a government,
or any other organization for insuring the payment of the cost of health care
services;

(d) Any agreement with providers for the
provision of health care services; and

(e) Any surety bond or deposit of cash or
securities submitted in accordance with NRS 695C.270
as a guarantee that the obligations will be duly performed.

5. The enrollees will be afforded an
opportunity to participate in matters of program content pursuant to NRS 695C.110.

6. Nothing in the proposed method of
operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070
and 695C.140, or by independent investigation is
contrary to the public interest.

NRS 695C.090Certificate of authority:
Issuance. [Effective January 1, 2014.]The
Commissioner shall issue or deny a certificate of authority to any person
filing an application pursuant to NRS 695C.060
within 90 days after certification. Issuance of a certificate of authority must
be granted upon payment of the fees prescribed in NRS
695C.230 if the Commissioner is satisfied that the following conditions are
met:

1. The persons responsible for the conduct
of the affairs of the applicant are competent, trustworthy and possess good
reputations.

2. The Commissioner certifies, in
accordance with NRS 695C.080, that the health
maintenance organization’s proposed plan of operation meets the requirements of
subsection 1 of NRS 695C.080.

3. The health care plan furnishes
comprehensive health care services.

4. The health maintenance organization is
financially responsible and may reasonably be expected to meet its obligations
to enrollees and prospective enrollees. In making this determination, the
Commissioner may consider:

(a) The financial soundness of the health care
plan’s arrangements for health care services and the schedule of charges used
in connection therewith;

(b) The adequacy of working capital;

(c) Any agreement with an insurer, a government,
or any other organization for insuring the payment of the cost of health care
services;

(d) Any agreement with providers for the
provision of health care services; and

(e) Any surety bond or deposit of cash or
securities submitted in accordance with NRS 695C.270
as a guarantee that the obligations will be duly performed.

5. The enrollees will be afforded an
opportunity to participate in matters of program content pursuant to NRS 695C.110.

6. Nothing in the proposed method of
operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070
and 695C.140, or by independent investigation is
contrary to the public interest.

NRS 695C.100Certificate of authority: Denial.A
certificate of authority shall be denied only after compliance with the
requirements of NRS 695C.340.

(Added to NRS by 1973, 1250)

NRS 695C.110Governing body: Composition; participation by enrollees.

1. The governing body of any health
maintenance organization may include providers, other individuals or both.

2. Such governing body shall establish a
mechanism to afford the enrollees an opportunity to participate in matters of
program content through the establishment of advisory panels, by the use of
advisory referenda on major policy decisions or through the use of other
mechanisms. In addition there shall be a provider advisory board to advise the
health plan in the matter of quality of care. There shall be a joint board of
consumers and providers to advise on consumer satisfaction.

(Added to NRS by 1973, 1250)

NRS 695C.120Powers of organization.The
powers of a health maintenance organization include, but are not limited to,
the following:

1. The purchase, lease, construction,
renovation, operation or maintenance of hospitals, medical facilities, or both,
and their ancillary equipment, and such property as may reasonably be required
for its principal office or for such other purposes as may be necessary in the
transaction of the business of the organization;

2. The making of loans to a medical group
under contract with it in furtherance of its program or the making of loans to
a corporation under its control for the purpose of acquiring or constructing
medical facilities and hospitals or in furtherance of a program providing
health care services to enrollees;

3. The furnishing of health care service
through providers which are under contract with or employed by the health
maintenance organization;

4. The contracting with any person for the
performance on its behalf of certain functions such as marketing, enrollment
and administration; and

5. The contracting with an insurance
company licensed in this state or authorized to do business in this state for
the provision of such insurance, indemnity, or reimbursement against the cost
of health care services provided by the health maintenance organization.

1. Except as otherwise provided in NRS 422.273, a health maintenance
organization that furnishes health care services through providers which are
under contract with the organization shall use its best efforts to contract
with at least one health center in each geographic area served by the
organization to provide such services to enrollees if the health center:

(a) Meets all conditions imposed by the
organization on similarly situated providers of health care that are under
contract with the organization, including, without limitation:

(1) Certification for participation in the
Medicaid or Medicare program; and

(2) Requirements relating to the
appropriate credentials for providers of health care; and

(b) Agrees to reasonable reimbursement rates that
are generally consistent with those offered by the organization to similarly
situated providers of health care that are under contract with the
organization.

2. As used in this section, “health
center” has the meaning ascribed to it in 42 U.S.C. § 254b.

NRS 695C.125Contract between health maintenance organization and provider of
health care: Form to obtain information on provider of health care;
modification; provision of schedule of fees.

1. A health maintenance organization shall
not contract with a provider of health care to provide health care to an
insured unless the health maintenance organization uses the form prescribed by
the Commissioner pursuant to NRS 629.095
to obtain any information related to the credentials of the provider of health
care.

2. A contract between a health maintenance
organization and a provider of health care may be modified:

(a) At any time pursuant to a written agreement
executed by both parties.

(b) Except as otherwise provided in this
paragraph, by the health maintenance organization upon giving to the provider
45 days’ written notice of the modification of the health maintenance
organization’s schedule of payments, including any changes to the fee schedule
applicable to the provider’s practice. If the provider fails to object in
writing to the modification within the 45-day period, the modification becomes
effective at the end of that period. If the provider objects in writing to the
modification within the 45-day period, the modification must not become
effective unless agreed to by both parties as described in paragraph (a).

3. If a health maintenance organization
contracts with a provider of health care to provide health care to an enrollee,
the health maintenance organization shall:

(a) If requested by the provider of health care
at the time the contract is made, submit to the provider of health care the
schedule of payments applicable to the provider of health care; or

(b) If requested by the provider of health care
at any other time, submit to the provider of health care the schedule of
payments, including any changes to the fee schedule applicable to the
provider’s practice, specified in paragraph (a) within 7 days after receiving
the request.

4. As used in this section, “provider of
health care” means a provider of health care who is licensed pursuant to chapter 630, 631,
632 or 633
of NRS.

NRS 695C.128Contracts to provide services pursuant to certain state
programs: Payment of interest on claims.Any
contract or other agreement entered into or renewed by a health maintenance
organization on or after October 1, 2001:

1. To provide health care services through
managed care to recipients of Medicaid under the state plan for Medicaid; or

2. With the Division of Health Care
Financing and Policy of the Department of Health and Human Services to provide
insurance pursuant to the Children’s Health Insurance Program,

Ê must require
the health maintenance organization to pay interest to a provider of health
care services on a claim that is not paid within the time provided in the
contract or agreement at a rate of interest equal to the prime rate at the
largest bank in Nevada, as ascertained by the Commissioner of Financial
Institutions, on January 1 or July 1, as the case may be, immediately preceding
the date on which the payment was due, plus 6 percent. The interest must be
calculated from 30 days after the date on which the claim is approved until the
date on which the claim is paid.

NRS 695C.130Notice and approval required for exercise of powers; rules or
regulations.

1. A health maintenance organization shall
file notice, with adequate supporting information, with the Commissioner prior
to the exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shall disapprove such
exercise of power if in the opinion of the Commissioner it would substantially
and adversely affect the financial soundness of the health maintenance
organization and endanger its ability to meet its obligations. If the
Commissioner does not disapprove within 60 days of the filing, it is deemed
approved.

2. The Commissioner may promulgate rules
or regulations.

(Added to NRS by 1973, 1250)

NRS 695C.140Notice and approval required for modification of operations;
regulations. [Effective through December 31, 2013.]

1. A health maintenance organization shall,
unless otherwise provided for in this chapter, file notice with the
Commissioner and the State Board of Health before any material modification of
the operations described in the information required by NRS
695C.070. If the Commissioner does not disapprove within 90 days after
filing of the notice, the modification is deemed approved.

2. The Commissioner may adopt regulations
to carry out the provisions of this section.

1. A health maintenance organization
shall, unless otherwise provided for in this chapter, file notice with the
Commissioner before any material modification of the operations described in
the information required by NRS 695C.070. If the
Commissioner does not disapprove within 90 days after filing of the notice, the
modification is deemed approved.

2. The Commissioner may adopt regulations
to carry out the provisions of this section.

NRS 695C.150Fiduciary responsibilities.Any
director, officer, partner, member or employee of a health maintenance
organization who receives, collects, disburses or invests funds in connection
with the activities of such organization shall be responsible for such funds in
a fiduciary relationship to the enrollees.

(Added to NRS by 1973, 1250)

NRS 695C.160Investments.With
the exception of investments made in accordance with subsections 1 and 2 of NRS 695C.120 and NRS
695C.130, the investable funds of a health maintenance organization shall
be invested only in securities or other investments permitted by the laws of
this state for the investment of assets constituting the legal reserves of life
insurance companies or such other securities or investments as the Commissioner
may permit.

1. “Medicaid” means a program established
in any state pursuant to Title XIX of the Social Security Act (42 U.S.C. §§
1396 et seq.) to provide assistance for part or all of the cost of medical care
rendered on behalf of indigent persons.

2. “Order for medical coverage” means an
order of a court or administrative tribunal to provide coverage under a health
care plan to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.

NRS 695C.163Eligibility for coverage: Effect of eligibility for medical
assistance under Medicaid; assignment of rights to state agency.

1. A health maintenance organization shall
not, when considering eligibility for coverage or making payments under a
health care plan, consider the availability of, or eligibility of a person for,
medical assistance under Medicaid.

2. To the extent that payment has been
made by Medicaid for health care, a health maintenance organization:

(a) Shall treat Medicaid as having a valid and
enforceable assignment of benefits due an enrollee or claimant under the
enrollee regardless of any exclusion of Medicaid or the absence of a written
assignment; and

(b) May, as otherwise allowed by its plan,
evidence of coverage or contract and applicable law or regulation concerning
subrogation, seek to enforce any rights of a recipient of Medicaid to
reimbursement against any other liable party if:

(1) It is so authorized pursuant to a
contract with Medicaid for managed care; or

(2) It has reimbursed Medicaid in full for
the health care provided by Medicaid to its enrollee.

3. If a state agency is assigned any
rights of a person who is:

(a) Eligible for medical assistance under
Medicaid; and

(b) Covered by a health care plan,

Ê the
organization responsible for the health care plan shall not impose any
requirements upon the state agency except requirements it imposes upon the
agents or assignees of other persons covered by the same plan.

4. If a state agency is assigned any
rights of an enrollee who is eligible for medical assistance under Medicaid, a
health maintenance organization shall:

(a) Upon request of the state agency, provide to
the state agency information regarding the enrollee to determine:

(1) Any period during which the enrollee,
the spouse or a dependent of the enrollee may be or may have been covered by
the health care plan; and

(2) The nature of the coverage that is or
was provided by the organization, including, without limitation, the name and
address of the enrollee and the identifying number of the health care plan;

(b) Respond to any inquiry by the state agency
regarding a claim for payment for the provision of any medical item or service
not later than 3 years after the date of the provision of the medical item or
service; and

(c) Agree not to deny a claim submitted by the
state agency solely on the basis of the date of submission of the claim, the
type or format of the claim form or failure to present proper documentation at
the point of sale that is the basis for the claim if:

(1) The claim is submitted by the state
agency not later than 3 years after the date of the provision of the medical
item or service; and

(2) Any action by the state agency to
enforce its rights with respect to such claim is commenced not later than 6
years after the submission of the claim.

NRS 695C.165Eligibility for coverage: Organization prohibited from asserting
certain grounds to deny enrollment of child pursuant to order if parent is
enrolled in health care plan.An
organization shall not deny the enrollment of a child pursuant to an order for
medical coverage under a health care plan in which a parent of the child is
enrolled, on the ground that the child:

1. Was born out of wedlock;

2. Has not been claimed as a dependent on
the parent’s federal income tax return; or

3. Does not reside with the parent or
within the organization’s geographic area of service.

NRS 695C.167Eligibility for coverage: Certain accommodations to be made when
child is covered under health care plan of noncustodial parent.If a child has coverage under a health care
plan in which a noncustodial parent of the child is enrolled, the organization
responsible for that plan shall:

1. Provide to the custodial parent such
information as necessary for the child to obtain any benefits under that
coverage.

2. Allow the custodial parent or, with the
approval of the custodial parent, a provider to submit claims for covered
services without the approval of the noncustodial parent.

3. Make payments on claims submitted
pursuant to subsection 2 directly to the custodial parent, the provider or an
agency of this or another state responsible for the administration of Medicaid.

NRS 695C.169Eligibility for coverage: Organization to authorize enrollment
of child of parent who is required by order to provide medical coverage under
certain circumstances; termination of coverage of child.If a parent is required by an order for
medical coverage to provide coverage for a child and the parent is eligible for
coverage of members of the parent’s family under a health care plan, the
organization responsible for that plan:

1. Shall, if the child is otherwise
eligible for that coverage, allow the parent to enroll the child in that
coverage without regard to any restrictions upon periods for enrollment.

2. Shall, if:

(a) The child is otherwise eligible for that
coverage; and

(b) The parent is enrolled in that coverage but
fails to apply for enrollment of the child,

Ê enroll the
child in that coverage upon application by the other parent of the child, or by
an agency of this or another state responsible for the administration of
Medicaid or a state program for the enforcement of child support established
pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon
periods for enrollment.

3. Shall not terminate the enrollment of
the child in that coverage or otherwise eliminate that coverage of the child
unless the organization has written proof that:

(a) The order for medical coverage is no longer
in effect; or

(b) The child is or will be enrolled in
comparable coverage through another insurer on or before the effective date of
the termination of enrollment or elimination of coverage.

1. The provisions of this section apply to
a health care plan offered or issued by a health maintenance organization if an
insured covered by the health care plan receives health care through a defined
set of providers of health care who are under contract with the health
maintenance organization.

2. Except as otherwise provided in this
section, if an insured who is covered by a health care plan described in
subsection 1 is receiving medical treatment for a medical condition from a
provider of health care whose contract with the health maintenance organization
is terminated during the course of the medical treatment, the health care plan
must provide that:

(a) The insured may continue to obtain medical
treatment for the medical condition from the provider of health care pursuant
to this section, if:

(1) The insured is actively undergoing a
medically necessary course of treatment; and

(2) The provider of health care and the
insured agree that the continuity of care is desirable.

(b) The provider of health care is entitled to
receive reimbursement from the health maintenance organization for the medical
treatment the provider of health care provides to the insured pursuant to this
section, if the provider of health care agrees:

(1) To provide medical treatment under the
terms of the contract between the provider of health care and the health
maintenance organization with regard to the insured, including, without limitation,
the rates of payment for providing medical service, as those terms existed
before the termination of the contract between the provider of health care and
the health maintenance organization; and

(2) Not to seek payment from the insured
for any medical service provided by the provider of health care that the
provider of health care could not have received from the insured were the
provider of health care still under contract with the health maintenance
organization.

3. The coverage required by subsection 2
must be provided until the later of:

(a) The 120th day after the date the contract is
terminated; or

(b) If the medical condition is pregnancy, the
45th day after:

(1) The date of delivery; or

(2) If the pregnancy does not end in
delivery, the date of the end of the pregnancy.

4. The requirements of this section do not
apply to a provider of health care if:

(a) The provider of health care was under
contract with the health maintenance organization and the health maintenance
organization terminated that contract because of the medical incompetence or
professional misconduct of the provider of health care; and

(b) The health maintenance organization did not
enter into another contract with the provider of health care after the contract
was terminated pursuant to paragraph (a).

5. An evidence of coverage for a health
care plan subject to the provisions of this chapter that is delivered, issued
for delivery or renewed on or after October 1, 2003, has the legal effect of
including the coverage required by this section, and any provision of the
evidence of coverage or renewal thereof that is in conflict with this section
is void.

6. The Commissioner shall adopt
regulations to carry out the provisions of this section.

NRS 695C.1693Required provision concerning coverage for treatment received as
part of clinical trial or study. [Effective through December 31, 2013.]

1. Except as otherwise provided in NRS 695C.050, a health care plan issued by a health
maintenance organization must provide coverage for medical treatment which an
enrollee receives as part of a clinical trial or study if:

(a) The medical treatment is provided in a Phase
I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of
cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;

(b) The clinical trial or study is approved by:

(1) An agency of the National Institutes
of Health as set forth in 42 U.S.C. § 281(b);

(2) A cooperative group;

(3) The Food and Drug Administration as an
application for a new investigational drug;

(4) The United States Department of
Veterans Affairs; or

(5) The United States Department of
Defense;

(c) In the case of:

(1) A Phase I clinical trial or study for
the treatment of cancer, the medical treatment is provided at a facility
authorized to conduct Phase I clinical trials or studies for the treatment of
cancer; or

(2) A Phase II, Phase III or Phase IV
study or clinical trial for the treatment of cancer or chronic fatigue syndrome,
the medical treatment is provided by a provider of health care and the facility
and personnel for the clinical trial or study have the experience and training
to provide the treatment in a capable manner;

(d) There is no medical treatment available which
is considered a more appropriate alternative medical treatment than the medical
treatment provided in the clinical trial or study;

(e) There is a reasonable expectation based on
clinical data that the medical treatment provided in the clinical trial or
study will be at least as effective as any other medical treatment;

(f) The clinical trial or study is conducted in
this State; and

(g) The enrollee has signed, before participating
in the clinical trial or study, a statement of consent indicating that the
enrollee has been informed of, without limitation:

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

(3) The risks associated with
participation in the clinical trial or study, including, without limitation,
the general nature and extent of such risks.

2. Except as otherwise provided in
subsection 3, the coverage for medical treatment required by this section is
limited to:

(a) Coverage for any drug or device that is
approved for sale by the Food and Drug Administration without regard to whether
the approved drug or device has been approved for use in the medical treatment
of the enrollee.

(b) The cost of any reasonably necessary health
care services that are required as a result of the medical treatment provided
in a Phase II, Phase III or Phase IV clinical trial or study or as a result of
any complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such health
care services would otherwise be covered under the health care plan.

(c) The cost of any routine health care services
that would otherwise be covered under the health care plan for an enrollee in a
Phase I clinical trial or study.

(d) The initial consultation to determine whether
the enrollee is eligible to participate in the clinical trial or study.

(e) Health care services required for the
clinically appropriate monitoring of the enrollee during a Phase II, Phase III
or Phase IV clinical trial or study.

(f) Health care services which are required for
the clinically appropriate monitoring of the enrollee during a Phase I clinical
trial or study and which are not directly related to the clinical trial or
study.

Ê Except as
otherwise provided in NRS 695C.1691, the services
provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if
the services are provided by a provider with whom the health maintenance
organization has contracted for such services. If the health maintenance
organization has not contracted for the provision of such services, the health
maintenance organization shall pay the provider the rate of reimbursement that
is paid to other providers with whom the health maintenance organization has
contracted for similar services and the provider shall accept that rate of
reimbursement as payment in full.

3. Particular medical treatment described
in subsection 2 and provided to an enrollee is not required to be covered
pursuant to this section if that particular medical treatment is provided by
the sponsor of the clinical trial or study free of charge to the enrollee.

4. The coverage for medical treatment
required by this section does not include:

(a) Any portion of the clinical trial or study
that is customarily paid for by a government or a biotechnical, pharmaceutical
or medical industry.

(b) Coverage for a drug or device described in
paragraph (a) of subsection 2 which is paid for by the manufacturer,
distributor or provider of the drug or device.

(c) Health care services that are specifically
excluded from coverage under the enrollee’s health care plan, regardless of
whether such services are provided under the clinical trial or study.

(d) Health care services that are customarily
provided by the sponsors of the clinical trial or study free of charge to the
participants in the trial or study.

(e) Extraneous expenses related to participation
in the clinical trial or study including, without limitation, travel, housing
and other expenses that a participant may incur.

(f) Any expenses incurred by a person who
accompanies the enrollee during the clinical trial or study.

(g) Any item or service that is provided solely
to satisfy a need or desire for data collection or analysis that is not
directly related to the clinical management of the enrollee.

(h) Any costs for the management of research
relating to the clinical trial or study.

5. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1
may require copies of the approval or certification issued pursuant to
paragraph (b) of subsection 1, the statement of consent signed by the enrollee,
protocols for the clinical trial or study and any other materials related to
the scope of the clinical trial or study relevant to the coverage of medical
treatment pursuant to this section.

6. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1
shall:

(a) Include in the disclosure required pursuant
to NRS 695C.193 notice to each enrollee of the
availability of the benefits required by this section.

(b) Provide the coverage required by this section
subject to the same deductible, copayment, coinsurance and other such
conditions for coverage that are required under the plan.

7. A health care plan subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 2006, has the legal effect of including the coverage
required by this section, and any provision of the plan that conflicts with
this section is void.

8. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1 is
immune from liability for:

(a) Any injury to an enrollee caused by:

(1) Any medical treatment provided to the
enrollee in connection with his or her participation in a clinical trial or
study described in this section; or

(2) An act or omission by a provider of
health care who provides medical treatment or supervises the provision of
medical treatment to the enrollee in connection with his or her participation
in a clinical trial or study described in this section.

(b) Any adverse or unanticipated outcome arising
out of an enrollee’s participation in a clinical trial or study described in
this section.

9. As used in this section:

(a) “Cooperative group” means a network of
facilities that collaborate on research projects and has established a peer
review program approved by the National Institutes of Health. The term
includes:

(1) The Clinical Trials Cooperative Group
Program; and

(2) The Community Clinical Oncology
Program.

(b) “Facility authorized to conduct Phase I
clinical trials or studies for the treatment of cancer” means a facility or an
affiliate of a facility that:

(1) Has in place a Phase I program which
permits only selective participation in the program and which uses clear-cut
criteria to determine eligibility for participation in the program;

(2) Operates a protocol review and
monitoring system which conforms to the standards set forth in the Policies
and Guidelines Relating to the Cancer-Center Support Grant published by the
Cancer Centers Branch of the National Cancer Institute;

(3) Employs at least two researchers and
at least one of those researchers receives funding from a federal grant;

(4) Employs at least three clinical
investigators who have experience working in Phase I clinical trials or studies
conducted at a facility designated as a comprehensive cancer center by the
National Cancer Institute;

(5) Possesses specialized resources for
use in Phase I clinical trials or studies, including, without limitation,
equipment that facilitates research and analysis in proteomics, genomics and
pharmacokinetics;

(6) Is capable of gathering, maintaining
and reporting electronic data; and

(7) Is capable of responding to audits
instituted by federal and state agencies.

NRS 695C.1693Required provision
concerning coverage for treatment received as part of clinical trial or study.
[Effective January 1, 2014.]

1. Except as otherwise provided in NRS 695C.050, a health care plan issued by a health
maintenance organization must provide coverage for medical treatment which an
enrollee receives as part of a clinical trial or study if:

(a) The medical treatment is provided in a Phase
I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of
cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;

(b) The clinical trial or study is approved by:

(1) An agency of the National Institutes
of Health as set forth in 42 U.S.C. § 281(b);

(2) A cooperative group;

(3) The Food and Drug Administration as an
application for a new investigational drug;

(4) The United States Department of
Veterans Affairs; or

(5) The United States Department of
Defense;

(c) In the case of:

(1) A Phase I clinical trial or study for
the treatment of cancer, the medical treatment is provided at a facility
authorized to conduct Phase I clinical trials or studies for the treatment of
cancer; or

(2) A Phase II, Phase III or Phase IV
study or clinical trial for the treatment of cancer or chronic fatigue
syndrome, the medical treatment is provided by a provider of health care and
the facility and personnel for the clinical trial or study have the experience
and training to provide the treatment in a capable manner;

(d) There is no medical treatment available which
is considered a more appropriate alternative medical treatment than the medical
treatment provided in the clinical trial or study;

(e) There is a reasonable expectation based on
clinical data that the medical treatment provided in the clinical trial or
study will be at least as effective as any other medical treatment;

(f) The clinical trial or study is conducted in
this State; and

(g) The enrollee has signed, before participating
in the clinical trial or study, a statement of consent indicating that the
enrollee has been informed of, without limitation:

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

(3) The risks associated with
participation in the clinical trial or study, including, without limitation,
the general nature and extent of such risks.

2. Except as otherwise provided in
subsection 3, the coverage for medical treatment required by this section is
limited to:

(a) Coverage for any drug or device that is
approved for sale by the Food and Drug Administration without regard to whether
the approved drug or device has been approved for use in the medical treatment
of the enrollee.

(b) The cost of any reasonably necessary health
care services that are required as a result of the medical treatment provided
in a Phase II, Phase III or Phase IV clinical trial or study or as a result of
any complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such health
care services would otherwise be covered under the health care plan.

(c) The cost of any routine health care services
that would otherwise be covered under the health care plan for an enrollee in a
Phase I clinical trial or study.

(d) The initial consultation to determine whether
the enrollee is eligible to participate in the clinical trial or study.

(e) Health care services required for the
clinically appropriate monitoring of the enrollee during a Phase II, Phase III
or Phase IV clinical trial or study.

(f) Health care services which are required for
the clinically appropriate monitoring of the enrollee during a Phase I clinical
trial or study and which are not directly related to the clinical trial or
study.

Ê Except as
otherwise provided in NRS 695C.1691, the services
provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if
the services are provided by a provider with whom the health maintenance
organization has contracted for such services. If the health maintenance
organization has not contracted for the provision of such services, the health
maintenance organization shall pay the provider the rate of reimbursement that
is paid to other providers with whom the health maintenance organization has
contracted for similar services and the provider shall accept that rate of
reimbursement as payment in full.

3. Particular medical treatment described
in subsection 2 and provided to an enrollee is not required to be covered
pursuant to this section if that particular medical treatment is provided by
the sponsor of the clinical trial or study free of charge to the enrollee.

4. The coverage for medical treatment
required by this section does not include:

(a) Any portion of the clinical trial or study
that is customarily paid for by a government or a biotechnical, pharmaceutical
or medical industry.

(b) Coverage for a drug or device described in
paragraph (a) of subsection 2 which is paid for by the manufacturer,
distributor or provider of the drug or device.

(c) Health care services that are specifically
excluded from coverage under the enrollee’s health care plan, regardless of
whether such services are provided under the clinical trial or study.

(d) Health care services that are customarily
provided by the sponsors of the clinical trial or study free of charge to the
participants in the trial or study.

(e) Extraneous expenses related to participation
in the clinical trial or study including, without limitation, travel, housing
and other expenses that a participant may incur.

(f) Any expenses incurred by a person who
accompanies the enrollee during the clinical trial or study.

(g) Any item or service that is provided solely
to satisfy a need or desire for data collection or analysis that is not
directly related to the clinical management of the enrollee.

(h) Any costs for the management of research
relating to the clinical trial or study.

5. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1
may require copies of the approval or certification issued pursuant to
paragraph (b) of subsection 1, the statement of consent signed by the enrollee,
protocols for the clinical trial or study and any other materials related to
the scope of the clinical trial or study relevant to the coverage of medical
treatment pursuant to this section.

6. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1
shall provide the coverage required by this section subject to the same
deductible, copayment, coinsurance and other such conditions for coverage that
are required under the plan.

7. A health care plan subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 2006, has the legal effect of including the coverage
required by this section, and any provision of the plan that conflicts with
this section is void.

8. A health maintenance organization that
delivers or issues for delivery a health care plan specified in subsection 1 is
immune from liability for:

(a) Any injury to an enrollee caused by:

(1) Any medical treatment provided to the
enrollee in connection with his or her participation in a clinical trial or
study described in this section; or

(2) An act or omission by a provider of
health care who provides medical treatment or supervises the provision of
medical treatment to the enrollee in connection with his or her participation
in a clinical trial or study described in this section.

(b) Any adverse or unanticipated outcome arising
out of an enrollee’s participation in a clinical trial or study described in
this section.

9. As used in this section:

(a) “Cooperative group” means a network of
facilities that collaborate on research projects and has established a peer
review program approved by the National Institutes of Health. The term
includes:

(1) The Clinical Trials Cooperative Group
Program; and

(2) The Community Clinical Oncology
Program.

(b) “Facility authorized to conduct Phase I
clinical trials or studies for the treatment of cancer” means a facility or an
affiliate of a facility that:

(1) Has in place a Phase I program which
permits only selective participation in the program and which uses clear-cut
criteria to determine eligibility for participation in the program;

(2) Operates a protocol review and
monitoring system which conforms to the standards set forth in the Policies
and Guidelines Relating to the Cancer-Center Support Grant published by the
Cancer Centers Branch of the National Cancer Institute;

(3) Employs at least two researchers and
at least one of those researchers receives funding from a federal grant;

(4) Employs at least three clinical
investigators who have experience working in Phase I clinical trials or studies
conducted at a facility designated as a comprehensive cancer center by the
National Cancer Institute;

(5) Possesses specialized resources for
use in Phase I clinical trials or studies, including, without limitation,
equipment that facilitates research and analysis in proteomics, genomics and
pharmacokinetics;

(6) Is capable of gathering, maintaining
and reporting electronic data; and

(7) Is capable of responding to audits
instituted by federal and state agencies.

1. Except as otherwise provided in
subsection 5, a health maintenance organization which offers or issues a health
care plan that provides coverage for prescription drugs or devices shall
include in the plan coverage for:

(a) Any type of drug or device for contraception;
and

(b) Any type of hormone replacement therapy,

Ê which is
lawfully prescribed or ordered and which has been approved by the Food and Drug
Administration.

(a) Require an enrollee to pay a higher
deductible, copayment or coinsurance or require a longer waiting period or
other condition for coverage for a prescription for a contraceptive or hormone
replacement therapy than is required for other prescription drugs covered by
the plan;

(b) Refuse to issue a health care plan or cancel
a health care plan solely because the person applying for or covered by the
plan uses or may use in the future any of the services listed in subsection 1;

(c) Offer or pay any type of material inducement
or financial incentive to an enrollee to discourage the enrollee from accessing
any of the services listed in subsection 1;

(d) Penalize a provider of health care who
provides any of the services listed in subsection 1 to an enrollee, including,
without limitation, reducing the reimbursement of the provider of health care;
or

(e) Offer or pay any type of material inducement,
bonus or other financial incentive to a provider of health care to deny,
reduce, withhold, limit or delay any of the services listed in subsection 1 to
an enrollee.

3. Except as otherwise provided in
subsection 5, evidence of coverage subject to the provisions of this chapter
that is delivered, issued for delivery or renewed on or after October 1, 1999,
has the legal effect of including the coverage required by subsection 1, and
any provision of the evidence of coverage or the renewal which is in conflict
with this section is void.

(b) Prohibit a health maintenance organization
from requiring an enrollee to pay a deductible, copayment or coinsurance for the
coverage required by paragraphs (a) and (b) of subsection 1 that is the same as
the enrollee is required to pay for other prescription drugs covered by the
plan.

5. A health maintenance organization which
offers or issues a health care plan and which is affiliated with a religious
organization is not required to provide the coverage required by paragraph (a)
of subsection 1 if the health maintenance organization objects on religious
grounds. The health maintenance organization shall, before the issuance of a
health care plan and before renewal of enrollment in such a plan, provide to
the group policyholder or prospective enrollee, as applicable, written notice
of the coverage that the health maintenance organization refuses to provide
pursuant to this subsection. The health maintenance organization shall provide
notice to each enrollee, at the time the enrollee receives his or her evidence
of coverage, that the health maintenance organization refused to provide
coverage pursuant to this subsection.

6. If a health maintenance organization
refuses, pursuant to subsection 5, to provide the coverage required by
paragraph (a) of subsection 1, an employer may otherwise provide for the
coverage for the employees of the employer.

7. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.

1. Except as otherwise provided in
subsection 5, a health maintenance organization that offers or issues a health
care plan which provides coverage for outpatient care shall include in the plan
coverage for any health care service related to contraceptives or hormone
replacement therapy.

(a) Require an enrollee to pay a higher
deductible, copayment or coinsurance or require a longer waiting period or
other condition for coverage for outpatient care related to contraceptives or
hormone replacement therapy than is required for other outpatient care covered
by the plan;

(b) Refuse to issue a health care plan or cancel
a health care plan solely because the person applying for or covered by the
plan uses or may use in the future any of the services listed in subsection 1;

(c) Offer or pay any type of material inducement
or financial incentive to an enrollee to discourage the enrollee from accessing
any of the services listed in subsection 1;

(d) Penalize a provider of health care who
provides any of the services listed in subsection 1 to an enrollee, including,
without limitation, reducing the reimbursement of the provider of health care;
or

(e) Offer or pay any type of material inducement,
bonus or other financial incentive to a provider of health care to deny,
reduce, withhold, limit or delay any of the services listed in subsection 1 to
an enrollee.

3. Except as otherwise provided in
subsection 5, evidence of coverage subject to the provisions of this chapter
that is delivered, issued for delivery or renewed on or after October 1, 1999,
has the legal effect of including the coverage required by subsection 1, and
any provision of the evidence of coverage or the renewal which is in conflict
with this section is void.

4. The provisions of this section do not
prohibit a health maintenance organization from requiring an enrollee to pay a
deductible, copayment or coinsurance for the coverage required by subsection 1
that is the same as the enrollee is required to pay for other outpatient care
covered by the plan.

5. A health maintenance organization which
offers or issues a health care plan and which is affiliated with a religious
organization is not required to provide the coverage for health care service
related to contraceptives required by this section if the health maintenance
organization objects on religious grounds. The health maintenance organization
shall, before the issuance of a health care plan and before renewal of
enrollment in such a plan, provide to the group policyholder or prospective
enrollee, as applicable, written notice of the coverage that the health
maintenance organization refuses to provide pursuant to this subsection. The
health maintenance organization shall provide notice to each enrollee, at the
time the enrollee receives his or her evidence of coverage, that the health
maintenance organization refused to provide coverage pursuant to this
subsection.

6. If a health maintenance organization
refuses, pursuant to subsection 5, to provide the coverage required by
paragraph (a) of subsection 1, an employer may otherwise provide for the
coverage for the employees of the employer.

7. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.

1. Every enrollee residing in this state
is entitled to evidence of coverage under a health care plan. If the enrollee
obtains coverage under a health care plan through an insurance policy, whether
by option or otherwise, the insurer shall issue the evidence of coverage.
Otherwise, the health maintenance organization shall issue the evidence of
coverage.

2. Evidence of coverage or amendment
thereto must not be issued or delivered to any person in this state until a
copy of the form of the evidence of coverage or amendment thereto has been
filed with and approved by the Commissioner.

3. An evidence of coverage:

(a) Must not contain any provisions or statements
which are unjust, unfair, inequitable, misleading, deceptive, which encourage
misrepresentation or which are untrue, misleading or deceptive as defined in
subsection 1 of NRS 695C.300; and

(b) Must contain a clear and complete statement,
if a contract, or a reasonably complete summary if a certificate, of:

(1) The health care services and the
insurance or other benefits, if any, to which the enrollee is entitled under
the health care plan;

(2) Any limitations on the services, kind
of services, benefits, or kind of benefits, to be provided, including any
deductible or copayment feature;

(3) Where and in what manner the services
may be obtained; and

(4) The total amount of payment for health
care services and the indemnity or service benefits, if any, which the enrollee
is obligated to pay.

Ê Any
subsequent change may be evidenced in a separate document issued to the
enrollee.

4. A copy of the form of the evidence of
coverage to be used in this state and any amendment thereto is subject to the
requirements for filing and approval of subsection 2 unless it is subject to
the jurisdiction of the Commissioner under the laws governing health insurance,
in which event the provisions for filing and approval of those laws apply. To
the extent that such provisions do not apply to the requirements in subsection
3, such provisions are amended to incorporate the requirements of subsection 3
in approving or disapproving an evidence of coverage required by subsection 2.

NRS 695C.1703Coverage for prescription drugs: Provision of notice and
information regarding use of formulary.

1. A health maintenance organization or
insurer that offers or issues evidence of coverage which provides coverage for
prescription drugs shall include with any evidence of that coverage provided to
an enrollee, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the organization
or insurer pursuant to subsection 2. The notice required by this subsection
must:

(a) Be in a language that is easily understood
and in a format that is easy to understand;

(b) Include an explanation of what a formulary
is; and

(c) If a formulary is used, include:

(1) An explanation of:

(I) How often the contents of the
formulary are reviewed; and

(II) The procedure and criteria for
determining which prescription drugs are included in and excluded from the
formulary; and

(2) The telephone number of the
organization or insurer for making a request for information regarding the
formulary pursuant to subsection 2.

2. If a health maintenance organization or
insurer offers or issues evidence of coverage which provides coverage for
prescription drugs and a formulary is used, the organization or insurer shall:

(a) Provide to any enrollee or participating
provider of health care upon request:

(1) Information regarding whether a
specific drug is included in the formulary.

(2) Access to the most current list of
prescription drugs in the formulary, organized by major therapeutic category,
with an indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the organization or insurer
shall notify the requester that a choice of formulary lists is available.

(b) Notify each person who requests information
regarding the formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.

NRS 695C.1705Group health care plan issued to replace discontinued policy or
coverage: Requirements; notice of reduction of benefits; statement of benefits;
applicability to self-insured employer. [Effective through December 31, 2013.]Except as otherwise provided in the provisions
of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the
portability and accountability of health insurance:

1. A group health care plan issued by a
health maintenance organization to replace any discontinued policy or coverage
for group health insurance must:

(a) Provide coverage for all persons who were
covered under the previous policy or coverage on the date it was discontinued;
and

(b) Except as otherwise provided in subsection 2,
provide benefits which are at least as extensive as the benefits provided by
the previous policy or coverage, except that benefits may be reduced or
excluded to the extent that such a reduction or exclusion was permissible under
the terms of the previous policy or coverage,

Ê if that plan
is issued within 60 days after the date on which the previous policy or
coverage was discontinued.

2. If an employer obtains a replacement
plan pursuant to subsection 1 to cover the employees of the employer, any
benefits provided by the previous policy or coverage may be reduced if notice
of the reduction is given to the employees pursuant to NRS 608.1577.

3. Any health maintenance organization
which issues a replacement plan pursuant to subsection 1 may submit a written
request to the insurer which provided the previous policy or coverage for a
statement of benefits which were provided under that policy or coverage. Upon
receiving such a request, the insurer shall give a written statement to the
organization indicating what benefits were provided and what exclusions or
reductions were in effect under the previous policy or coverage.

4. If an employee or enrollee was a
recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not
entitled to have issued to him or her by a health maintenance organization a
replacement plan unless the employee or enrollee has reported for his or her
normal employment for a period of 90 consecutive days after last being eligible
to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

5. The provisions of this section apply to
a self-insured employer who provides health benefits to the employees of the
self-insured employer and replaces those benefits with a group health care plan
issued by a health maintenance organization.

NRS 695C.1705Group health care plan
issued to replace discontinued policy or coverage: Requirements; notice of
reduction of benefits; statement of benefits; applicability to self-insured
employer. [Effective January 1, 2014.]Except
as otherwise provided in the provisions of NRS
689B.340 to 689B.580, inclusive,
and chapter 689C of NRS relating to the
portability and accountability of health insurance:

1. A group health care plan issued by a
health maintenance organization to replace any discontinued policy or coverage
for group health insurance must:

(a) Provide coverage for all persons who were
covered under the previous policy or coverage on the date it was discontinued;
and

(b) Except as otherwise provided in subsection 2,
provide benefits which are at least as extensive as the benefits provided by
the previous policy or coverage, except that benefits may be reduced or
excluded to the extent that such a reduction or exclusion was permissible under
the terms of the previous policy or coverage,

Ê if that plan
is issued within 60 days after the date on which the previous policy or
coverage was discontinued.

2. If an employer obtains a replacement
plan pursuant to subsection 1 to cover the employees of the employer, any
benefits provided by the previous policy or coverage may be reduced if notice
of the reduction is given to the employees pursuant to NRS 608.1577.

3. Any health maintenance organization
which issues a replacement plan pursuant to subsection 1 may submit a written
request to the insurer which provided the previous policy or coverage for a
statement of benefits which were provided under that policy or coverage. Upon
receiving such a request, the insurer shall give a written statement to the
organization indicating what benefits were provided and what exclusions or
reductions were in effect under the previous policy or coverage.

4. If an employee or enrollee was a
recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not
entitled to have issued to him or her by a health maintenance organization a
replacement plan unless the employee or enrollee has reported for his or her
normal employment for a period of 90 consecutive days after last being eligible
to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

5. The provisions of this section apply to
a self-insured employer who provides health benefits to the employees of the
self-insured employer and replaces those benefits with a group health care plan
issued by a health maintenance organization.

NRS 695C.1707Required provision for continuation of coverage. [Effective through
December 31, 2013.]Any policy of
group insurance to which an enrollee is entitled under a health care plan
provided by a health maintenance organization must contain a provision which
permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive, 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the
portability and accountability of health insurance.

NRS 695C.1709Required provision concerning coverage for enrollee on leave
without pay as result of total disability.

1. As used in this section, “total
disability” and “totally disabled” mean the continuing inability of the
enrollee, because of an injury or illness, to perform substantially the duties
related to his or her employment for which the enrollee is otherwise qualified.

2. No policy of group insurance to which
an enrollee is entitled under a health care plan provided by a health
maintenance organization may be delivered or issued for delivery in this state
unless it provides continuing coverage for an enrollee and dependents of the
enrollee who are otherwise covered by the policy while the enrollee is on leave
without pay as a result of a total disability. The coverage must be for any
injury or illness suffered by the enrollee which is not related to the total
disability or for any injury or illness suffered by a dependent of the
enrollee. The coverage must be equal to or greater than the coverage otherwise
provided by the policy.

1. A health maintenance plan which
provides coverage for the surgical procedure known as a mastectomy must also
provide commensurate coverage for:

(a) Reconstruction of the breast on which the
mastectomy has been performed;

(b) Surgery and reconstruction of the other
breast to produce a symmetrical structure; and

(c) Prostheses and physical complications for all
stages of mastectomy, including lymphedemas.

2. The provision of services must be
determined by the attending physician and the patient.

3. The plan or issuer may require
deductibles and coinsurance payments if they are consistent with those
established for other benefits.

4. Written notice of the availability of
the coverage must be given upon enrollment and annually thereafter. The notice
must be sent to all participants:

(a) In the next mailing made by the plan or
issuer to the participant or beneficiary; or

(b) As part of any annual information packet sent
to the participant or beneficiary,

Ê whichever is
earlier.

5. A plan or issuer may not:

(a) Deny eligibility, or continued eligibility,
to enroll or renew coverage, in order to avoid the requirements of subsections
1 to 4, inclusive; or

(b) Penalize, or limit reimbursement to, a
provider of care, or provide incentives to a provider of care, in order to
induce the provider not to provide the care listed in subsections 1 to 4,
inclusive.

6. A plan or issuer may negotiate rates of
reimbursement with providers of care.

7. If reconstructive surgery is begun
within 3 years after a mastectomy, the amount of the benefits for that surgery
must equal those amounts provided for in the policy at the time of the
mastectomy. If the surgery is begun more than 3 years after the mastectomy, the
benefits provided are subject to all of the terms, conditions and exclusions
contained in the policy at the time of the reconstructive surgery.

8. A policy subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or after
October 1, 2001, has the legal effect of including the coverage required by
this section, and any provision of the policy or the renewal which is in
conflict with this section is void.

9. For the purposes of this section,
“reconstructive surgery” means a surgical procedure performed following a
mastectomy on one breast or both breasts to re-establish symmetry between the
two breasts. The term includes, but is not limited to, augmentation
mammoplasty, reduction mammoplasty and mastopexy.

1. A health care plan must include a
provision authorizing a woman covered by the plan to obtain covered
gynecological or obstetrical services without first receiving authorization or
a referral from her primary care physician.

2. The provisions of this section do not
authorize a woman covered by a health care plan to designate an obstetrician or
gynecologist as her primary care physician.

3. An evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after October 1, 1999, has the legal effect of including the coverage
required by this section, and any provision of the evidence of coverage or the
renewal which is in conflict with this section is void.

4. As used in this section, “primary care
physician” has the meaning ascribed to it in NRS 695G.060.

1. A health care plan issued by a health
maintenance organization must provide coverage for screening for and diagnosis
of autism spectrum disorders and for treatment of autism spectrum disorders to
persons covered by the health care plan under the age of 18 or, if enrolled in
high school, until the person reaches the age of 22.

2. Coverage provided under this section is
subject to:

(a) A maximum benefit of $36,000 per year for
applied behavior analysis treatment; and

(b) Copayment, deductible and coinsurance
provisions and any other general exclusion or limitation of a health care plan
to the same extent as other medical services or prescription drugs covered by
the plan.

(a) Require an enrollee to pay a higher
deductible, copayment or coinsurance or require a longer waiting period for
coverage for outpatient care related to autism spectrum disorders than is
required for other outpatient care covered by the plan; or

(b) Refuse to issue a health care plan or cancel
a health care plan solely because the person applying for or covered by the
plan uses or may use in the future any of the services listed in subsection 1.

4. Except as provided in subsections 1 and
2, a health maintenance organization shall not limit the number of visits an
enrollee may make to any person, entity or group for treatment of autism
spectrum disorders.

5. Treatment of autism spectrum disorders
must be identified in a treatment plan and may include medically necessary
habilitative or rehabilitative care, prescription care, psychiatric care,
psychological care, behavior therapy or therapeutic care that is:

(a) Prescribed for a person diagnosed with an
autism spectrum disorder by a licensed physician or licensed psychologist; and

(b) Provided for a person diagnosed with an
autism spectrum disorder by a licensed physician, licensed psychologist,
licensed behavior analyst or other provider that is supervised by the licensed
physician, psychologist or behavior analyst.

Ê A health
maintenance organization may request a copy of and review a treatment plan
created pursuant to this subsection.

6. Evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 2011, has the legal effect of including the coverage
required by subsection 1, and any provision of the evidence of coverage or the
renewal which is in conflict with subsection 1 or 2 is void.

7. Nothing in this section shall be
construed as requiring a health maintenance organization to provide
reimbursement to an early intervention agency or school for services delivered
through early intervention or school services.

8. As used in this section:

(a) “Applied behavior analysis” means the design,
implementation and evaluation of environmental modifications using behavioral
stimuli and consequences to produce socially significant improvement in human
behavior, including, without limitation, the use of direct observation,
measurement and functional analysis of the relations between environment and
behavior.

(d) “Certified autism behavior interventionist”
means a person who is certified as an autism behavior interventionist by the
Board of Psychological Examiners and who provides behavior therapy under the
supervision of:

(f) “Habilitative or rehabilitative care” means
counseling, guidance and professional services and treatment programs,
including, without limitation, applied behavior analysis, that are necessary to
develop, maintain and restore, to the maximum extent practicable, the
functioning of a person.

(g) “Licensed assistant behavior analyst” means a
person who holds current certification or meets the standards to be certified
as a board certified assistant behavior analyst issued by the Behavior Analyst
Certification Board, Inc., or any successor in interest to that organization,
who is licensed as an assistant behavior analyst by the Board of Psychological
Examiners and who provides behavioral therapy under the supervision of a
licensed behavior analyst or psychologist.

(h) “Licensed behavior analyst” means a person
who holds current certification or meets the standards to be certified as a
board certified behavior analyst or a board certified assistant behavior
analyst issued by the Behavior Analyst Certification Board, Inc., or any
successor in interest to that organization and who is licensed as a behavior
analyst by the Board of Psychological Examiners.

(i) “Prescription care” means medications
prescribed by a licensed physician and any health-related services deemed
medically necessary to determine the need or effectiveness of the medications.

(j) “Psychiatric care” means direct or
consultative services provided by a psychiatrist licensed in the state in which
the psychiatrist practices.

(k) “Psychological care” means direct or
consultative services provided by a psychologist licensed in the state in which
the psychologist practices.

(n) “Treatment plan” means a plan to treat an
autism spectrum disorder that is prescribed by a licensed physician or licensed
psychologist and may be developed pursuant to a comprehensive evaluation in
coordination with a licensed behavior analyst.

1. No health maintenance organization may
issue evidence of coverage under a health care plan to any enrollee in this
state if it contains any exclusion, reduction or other limitation of coverage
relating to complications of pregnancy unless the provision applies generally
to all benefits payable under the policy and complies with the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the
portability and accountability of health insurance.

2. As used in this section, the term
“complications of pregnancy” includes any condition which requires hospital
confinement for medical treatment and:

(a) If the pregnancy is not terminated, is caused
by an injury or sickness not directly related to the pregnancy or by acute
nephritis, nephrosis, cardiac decompensation, missed abortion or similar
medically diagnosed conditions; or

(b) If the pregnancy is terminated, results in
nonelective cesarean section, ectopic pregnancy or spontaneous termination.

3. Evidence of coverage under a health
care plan subject to the provisions of this chapter which is issued on or after
July 1, 1977, has the legal effect of including the coverage required by this
section, and any provision which is in conflict with this section is void.

1. No health maintenance organization may
issue evidence of coverage under a health care plan to any enrollee in this
state if it contains any exclusion, reduction or other limitation of coverage
relating to complications of pregnancy unless the provision applies generally
to all benefits payable under the policy and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the
portability and accountability of health insurance.

2. As used in this section, the term
“complications of pregnancy” includes any condition which requires hospital
confinement for medical treatment and:

(a) If the pregnancy is not terminated, is caused
by an injury or sickness not directly related to the pregnancy or by acute
nephritis, nephrosis, cardiac decompensation, missed abortion or similar
medically diagnosed conditions; or

(b) If the pregnancy is terminated, results in
nonelective cesarean section, ectopic pregnancy or spontaneous termination.

3. Evidence of coverage under a health
care plan subject to the provisions of this chapter which is issued on or after
July 1, 1977, has the legal effect of including the coverage required by this
section, and any provision which is in conflict with this section is void.

(a) Enteral formulas for use at home that are
prescribed or ordered by a physician as medically necessary for the treatment
of inherited metabolic diseases characterized by deficient metabolism, or
malabsorption originating from congenital defects or defects arising shortly
after birth, of amino acid, organic acid, carbohydrate or fat; and

(b) At least $2,500 per year for special food
products which are prescribed or ordered by a physician as medically necessary
for the treatment of a person described in paragraph (a).

2. The coverage required by subsection 1
must be provided whether or not the condition existed when the health
maintenance plan was purchased.

3. Any evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 1998, has the legal effect of including the coverage
required by this section, and any provision of the evidence of coverage or the
renewal which is in conflict with this section is void.

4. As used in this section:

(a) “Inherited metabolic disease” means a disease
caused by an inherited abnormality of the body chemistry of a person.

(b) “Special food product” means a food product
that is specially formulated to have less than one gram of protein per serving
and is intended to be consumed under the direction of a physician for the
dietary treatment of an inherited metabolic disease. The term does not include
a food that is naturally low in protein.

NRS 695C.1727Required provision concerning coverage for management and
treatment of diabetes. [Effective through December 31, 2013.]

1. No evidence of coverage that provides
coverage for hospital, medical or surgical expenses may be delivered or issued
for delivery in this state unless the evidence of coverage includes coverage
for the management and treatment of diabetes, including, without limitation,
coverage for the self-management of diabetes.

2. An insurer who delivers or issues for
delivery an evidence of coverage specified in subsection 1:

(a) Shall include in the disclosure required
pursuant to NRS 695C.193 notice to each enrollee
under the evidence of coverage of the availability of the benefits required by
this section.

(b) Shall provide the coverage required by this
section subject to the same deductible, copayment, coinsurance and other such
conditions for the evidence of coverage that are required under the evidence of
coverage.

3. Evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 1998, has the legal effect of including the coverage
required by this section, and any provision of the evidence of coverage that
conflicts with this section is void.

4. As used in this section:

(a) “Coverage for the management and treatment of
diabetes” includes coverage for medication, equipment, supplies and appliances
that are medically necessary for the treatment of diabetes.

(b) “Coverage for the self-management of
diabetes” includes:

(1) The training and education provided to
the enrollee after the enrollee is initially diagnosed with diabetes which is
medically necessary for the care and management of diabetes, including, without
limitation, counseling in nutrition and the proper use of equipment and
supplies for the treatment of diabetes;

(2) Training and education which is
medically necessary as a result of a subsequent diagnosis that indicates a
significant change in the symptoms or condition of the enrollee and which
requires modification of the enrollee’s program of self-management of diabetes;
and

(3) Training and education which is
medically necessary because of the development of new techniques and treatment
for diabetes.

1. No evidence of coverage that provides
coverage for hospital, medical or surgical expenses may be delivered or issued
for delivery in this state unless the evidence of coverage includes coverage
for the management and treatment of diabetes, including, without limitation,
coverage for the self-management of diabetes.

2. An insurer who delivers or issues for
delivery an evidence of coverage specified in subsection 1 shall provide the
coverage required by this section subject to the same deductible, copayment,
coinsurance and other such conditions for the evidence of coverage that are
required under the evidence of coverage.

3. Evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after January 1, 1998, has the legal effect of including the coverage
required by this section, and any provision of the evidence of coverage that
conflicts with this section is void.

4. As used in this section:

(a) “Coverage for the management and treatment of
diabetes” includes coverage for medication, equipment, supplies and appliances
that are medically necessary for the treatment of diabetes.

(b) “Coverage for the self-management of
diabetes” includes:

(1) The training and education provided to
the enrollee after the enrollee is initially diagnosed with diabetes which is
medically necessary for the care and management of diabetes, including, without
limitation, counseling in nutrition and the proper use of equipment and
supplies for the treatment of diabetes;

(2) Training and education which is
medically necessary as a result of a subsequent diagnosis that indicates a
significant change in the symptoms or condition of the enrollee and which
requires modification of the enrollee’s program of self-management of diabetes;
and

(3) Training and education which is
medically necessary because of the development of new techniques and treatment
for diabetes.

NRS 695C.173Required provision concerning coverage for newly born and
adopted children and children placed for adoption.

1. All individual and group health care
plans which provide coverage for a family member of the enrollee must as to
such coverage provide that the health care services applicable for children are
payable with respect to:

(a) A newly born child of the enrollee from the
moment of birth;

(b) An adopted child from the date the adoption
becomes effective, if the child was not placed in the home before adoption; and

(c) A child placed with the enrollee for the
purpose of adoption from the moment of placement as certified by the public or
private agency making the placement. The coverage of such a child ceases if the
adoption proceedings are terminated as certified by the public or private
agency making the placement.

Ê The plans
must provide the coverage specified in subsection 3, and must not exclude
premature births.

2. The evidence of coverage may require
that notification of:

(a) The birth of a newly born child;

(b) The effective date of adoption of a child; or

(c) The date of placement of a child for
adoption,

Ê and payments
of the required charge, if any, must be furnished to the health maintenance
organization within 31 days after the date of birth, adoption or placement for
adoption in order to have the coverage continue beyond the 31-day period.

3. The coverage for newly born and adopted
children and children placed for adoption consists of preventive health care
services as well as coverage of injury or sickness, including the necessary
care and treatment of medically diagnosed congenital defects and birth
abnormalities and, within the limits of the policy, necessary transportation
costs from place of birth to the nearest specialized treatment center under
major medical policies, and with respect to basic policies to the extent such
costs are charged by the treatment center.

4. A health maintenance organization shall
not restrict the coverage of a dependent child adopted or placed for adoption
solely because of a preexisting condition the child has at the time the child
would otherwise become eligible for coverage pursuant to that plan. Any
provision relating to an exclusion for a preexisting condition must comply with
NRS 689B.500 or 689C.190, as appropriate.

5. For covered services provided to the
child, the health maintenance organization shall reimburse noncontracted
providers of health care to an amount equal to the average amount of payment
for which the organization has agreements, contracts or arrangements for those
covered services.

1. A health care plan issued by a health
maintenance organization that provides coverage for the treatment of colorectal
cancer must provide coverage for colorectal cancer screening in accordance
with:

(a) The guidelines concerning colorectal cancer
screening which are published by the American Cancer Society; or

(b) Other guidelines or reports concerning
colorectal cancer screening which are published by nationally recognized
professional organizations and which include current or prevailing supporting
scientific data.

2. An evidence of coverage for a health
care plan subject to the provisions of this chapter that is delivered, issued
for delivery or renewed on or after October 1, 2003, has the legal effect of
including the coverage required by this section, and any provision of the
evidence of coverage that conflicts with the provisions of this section is
void.

1. No evidence of coverage that provides
coverage for a drug approved by the Food and Drug Administration for use in the
treatment of an illness, disease or other medical condition may be delivered or
issued for delivery in this state unless the evidence of coverage includes
coverage for any other use of the drug for the treatment of cancer, if that use
is:

(a) Specified in the most recent edition of or
supplement to:

(1) The United States Pharmacopoeia Drug
Information; or

(2) The American Hospital Formulary
Service Drug Information; or

(b) Supported by at least two articles reporting
the results of scientific studies that are published in scientific or medical
journals, as defined in 21 C.F.R. § 99.3.

2. The coverage required pursuant to this
section:

(a) Includes coverage for any medical services
necessary to administer the drug to the enrollee.

(b) Does not include coverage for any:

(1) Experimental drug used for the
treatment of cancer if that drug has not been approved by the Food and Drug
Administration; or

(2) Use of a drug that is contraindicated
by the Food and Drug Administration.

3. Any evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or renewed on
or after October 1, 1999, has the legal effect of including the coverage
required by this section, and any provision of the evidence of coverage that
conflicts with the provisions of this section is void.

1. A health maintenance organization that
offers or issues a health care plan which provides coverage for the treatment
of cancer through the use of chemotherapy shall not:

(a) Require a copayment, deductible or
coinsurance amount for chemotherapy administered orally by means of a
prescription drug in a combined amount that is more than $100 per prescription.
The limitation on the amount of the deductible that may be required pursuant to
this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan
is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount
of the annual deductible has not been satisfied.

(b) Make the coverage subject to monetary limits
that are less favorable for chemotherapy administered orally by means of a
prescription drug than the monetary limits applicable to chemotherapy which is
administered by injection or intravenously.

(c) Decrease the monetary limits applicable to
such chemotherapy administered orally by means of a prescription drug or to
chemotherapy which is administered by injection or intravenously to meet the
requirements of this section.

2. Evidence of coverage subject to the
provisions of this chapter which provides coverage for the treatment of cancer
through the use of chemotherapy and that is delivered, issued for delivery or
renewed on or after January 1, 2015, has the legal effect of providing that
coverage subject to the requirements of this section, and any provision of the
evidence of coverage or the renewal which is in conflict with this section is
void.

3. Nothing in this section shall be
construed as requiring a health maintenance organization to provide coverage
for the treatment of cancer through the use of chemotherapy administered by
injection or intravenously or administered orally by means of a prescription
drug.

1. Except as otherwise provided in this
section, evidence of coverage which provides coverage for prescription drugs
must not limit or exclude coverage for a drug if the drug:

(a) Had previously been approved for coverage by
the health maintenance organization or insurer for a medical condition of an enrollee
and the enrollee’s provider of health care determines, after conducting a
reasonable investigation, that none of the drugs which are otherwise currently
approved for coverage are medically appropriate for the enrollee; and

(b) Is appropriately prescribed and considered
safe and effective for treating the medical condition of the enrollee.

2. The provisions of subsection 1 do not:

(a) Apply to coverage for any drug that is
prescribed for a use that is different from the use for which that drug has
been approved for marketing by the Food and Drug Administration;

(b) Prohibit:

(1) The health maintenance organization or
insurer from charging a deductible, copayment or coinsurance for the provision
of benefits for prescription drugs to the enrollee or from establishing, by
contract, limitations on the maximum coverage for prescription drugs;

(2) A provider of health care from
prescribing another drug covered by the evidence of coverage that is medically
appropriate for the enrollee; or

(c) Require any coverage for a drug after the
term of the evidence of coverage.

3. Any provision of an evidence of
coverage subject to the provisions of this chapter that is delivered, issued
for delivery or renewed on or after October 1, 2001, which is in conflict with
this section is void.

(a) An annual cytologic
screening test for women 18 years of age or older;

(b) A baseline
mammogram for women between the ages of 35 and 40; and

(c) An annual mammogram
for women 40 years of age or older.

2. A health
maintenance plan must not require an insured to obtain prior authorization for
any service provided pursuant to subsection 1.

3. A policy
subject to the provisions of this chapter which is delivered, issued for
delivery or renewed on or after October 1, 1989, has the legal effect of
including the coverage required by subsection 1, and any provision of the
policy or the renewal which is in conflict with subsection 1 is void.

1. A health care plan of a health
maintenance organization must provide coverage for benefits payable for
expenses incurred for administering the human papillomavirus vaccine to women
and girls at such ages as recommended for vaccination by a competent authority,
including, without limitation, the Centers for Disease Control and Prevention
of the United States Department of Health and Human Services, the Food and Drug
Administration or the manufacturer of the vaccine.

2. A health care plan of a health
maintenance organization must not require an insured to obtain prior
authorization for any service provided pursuant to subsection 1.

3. Any evidence of coverage subject to the
provisions of this chapter which is delivered, issued for delivery or renewed
on or after July 1, 2007, has the legal effect of including the coverage
required by subsection 1, and any provision of the evidence of coverage or the
renewal which is in conflict with subsection 1 is void.

4. For the purposes of this section, “human
papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant
Vaccine or its successor which is approved by the Food and Drug Administration
for the prevention of human papillomavirus infection and cervical cancer.

1. A health care plan of a health
maintenance organization must provide coverage for benefits payable for
expenses incurred for administering the human papillomavirus vaccine as
recommended for vaccination by a competent authority, including, without
limitation, the Centers for Disease Control and Prevention of the United States
Department of Health and Human Services, the Food and Drug Administration or
the manufacturer of the vaccine.

2. A health care plan of a health
maintenance organization must not require an insured to obtain prior
authorization for any service provided pursuant to subsection 1.

3. Any evidence of coverage subject to the
provisions of this chapter which is delivered, issued for delivery or renewed
on or after July 1, 2007, has the legal effect of including the coverage
required by subsection 1, and any provision of the evidence of coverage or the
renewal which is in conflict with subsection 1 is void.

4. For the purposes of this section, “human
papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant
Vaccine or its successor which is approved by the Food and Drug Administration
for the prevention of human papillomavirus infection and cervical cancer.

1. A health care plan of a health
maintenance organization that provides coverage for the treatment of prostate
cancer must provide coverage for prostate cancer screening in accordance with:

(a) The guidelines concerning prostate cancer
screening which are published by the American Cancer Society; or

(b) Other guidelines or reports concerning
prostate cancer screening which are published by nationally recognized
professional organizations and which include current or prevailing supporting
scientific data.

2. A health care plan of a health
maintenance organization that provides coverage for the treatment of prostate
cancer must not require an insured to obtain prior authorization for any
service provided pursuant to subsection 1.

3. Any evidence of coverage for a health
care plan of a health maintenance organization that provides coverage for the
treatment of prostate cancer which is delivered, issued for delivery or renewed
on or after July 1, 2007, has the legal effect of including the coverage
required by subsection 1, and any provision of the evidence of coverage or the
renewal which is in conflict with subsection 1 is void.

1. Except as otherwise provided in this
section, no evidence of coverage may be delivered or issued for delivery in
this state if it contains an exclusion of coverage of the treatment of the
temporomandibular joint whether by specific language in the evidence of
coverage or by a claims settlement practice. An evidence of coverage may
exclude coverage of those methods of treatment which are recognized as dental
procedures, including, but not limited to, the extraction of teeth and the
application of orthodontic devices and splints.

2. The health maintenance organization may
limit its liability on the treatment of the temporomandibular joint to:

(a) No more than 50 percent of the usual and
customary charges for such treatment actually received by an enrollee, but in
no case more than 50 percent of the maximum benefits provided by the evidence
of coverage for such treatment; and

(b) Treatment which is medically necessary.

3. Any provision of an evidence of
coverage subject to the provisions of this chapter and issued or delivered on
or after January 1, 1990, which is in conflict with this section is void.

NRS 695C.1765Reimbursement for acupuncture.If
any evidence of coverage provides coverage for acupuncture performed by a
physician, the insured is entitled to reimbursement for acupuncture performed
by a person who is licensed pursuant to chapter
634A of NRS.

NRS 695C.177Reimbursement for treatments by licensed psychologist.If any evidence of coverage provides coverage for
treatment of an illness which is within the authorized scope of the practice of
a qualified psychologist, the insured is entitled to reimbursement for
treatments by a psychologist who is licensed pursuant to chapter 641 of NRS.

NRS 695C.1773Reimbursement for treatment by licensed marriage and family
therapist or licensed clinical professional counselor.If
any evidence of coverage provides coverage for treatment of an illness which is
within the authorized scope of practice of a licensed marriage and family
therapist or licensed clinical professional counselor, the insured is entitled
to reimbursement for treatment by a marriage and family therapist or clinical
professional counselor who is licensed pursuant to chapter 641A of NRS.

NRS 695C.1775Reimbursement for treatment by licensed associate in social
work, social worker, independent social worker or clinical social worker.If any evidence of coverage provides coverage
for treatment of an illness which is within the authorized scope of the
practice of a licensed associate in social work, social worker, independent
social worker or clinical social worker, the insured is entitled to reimbursement
for treatment by an associate in social work, social worker, independent social
worker or clinical social worker who is licensed pursuant to chapter 641B of NRS.

1. If any evidence of coverage provides
coverage for treatment of an illness which is within the authorized scope of
practice of a qualified chiropractor, the insured is entitled to reimbursement
for treatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.

2. The terms of the policy must not limit:

(a) Coverage for treatments by a chiropractor to
a number less than for treatments by other physicians.

(b) Reimbursement for treatments by a
chiropractor to an amount less than that charged for similar treatments by
other physicians.

(Added to NRS by 1981, 930; A 1983, 328)

NRS 695C.1783Reimbursement for treatment by podiatrist.

1. If any evidence of coverage provides
coverage for treatment of an illness which is within the authorized scope of
practice of a qualified podiatrist, the insured is entitled to reimbursement
for treatments by a podiatrist who is licensed pursuant to chapter 635 of NRS.

2. The terms of the policy must not limit:

(a) Coverage for treatments by a podiatrist to a
number less than for treatments by other physicians.

(b) Reimbursement for treatments by a podiatrist
to an amount less than that reimbursed for similar treatments by other
physicians.

NRS 695C.1789Reimbursement for treatment by licensed clinical alcohol and
drug abuse counselor.If any
evidence of coverage provides coverage for treatment of an illness which is
within the authorized scope of practice of a licensed clinical alcohol and drug
abuse counselor, the insured is entitled to reimbursement for treatment by a
clinical alcohol and drug abuse counselor who is licensed pursuant to chapter 641C of NRS.

1. If any evidence of coverage provides
coverage for services which are within the authorized scope of practice of a
registered nurse who is authorized pursuant to chapter
632 of NRS to perform additional acts in an emergency or under other
special conditions as prescribed by the State Board of Nursing, and which are
reimbursed when provided by another provider of health care, the insured is
entitled to reimbursement for services provided by such a registered nurse.

2. The terms of the evidence of coverage
must not limit:

(a) Coverage for services provided by such a
registered nurse to a number of occasions less than for services provided by
another provider of health care.

(b) Reimbursement for services provided by such a
registered nurse to an amount less than that reimbursed for similar services
provided by another provider of health care.

3. An insurer is not required to pay for
services provided by such a registered nurse which duplicate services provided
by another provider of health care.

1. Except as otherwise provided in
subsection 3, every evidence of coverage amended, delivered or issued for
delivery in this State after October 1, 1989, that provides coverage for
medical transportation, must contain a provision for the direct reimbursement
of a provider of medical transportation for covered services if that provider
does not receive reimbursement from any other source.

2. The enrollee or the provider may submit
the claim for reimbursement. The provider shall not demand payment from the
enrollee until after that reimbursement has been granted or denied.

3. Subsection 1 does not apply to any
agreement between a health maintenance organization and a provider of medical
transportation for the direct payment by the organization for the provider’s
services.

NRS 695C.180Schedule of charges. [Effective through December 31, 2013.]

1. No schedule of charges for enrollee
coverage for health care services or amendment thereto may be used in
conjunction with any health care plan until a copy of such schedule or
amendment thereto has been filed with and approved by the Commissioner.

2. Such charges may be established in
accordance with actuarial principles for various categories of enrollees.
However the charges shall not be excessive, inadequate nor unfairly
discriminatory. A certification by a qualified actuary to the adequacy of the
charges shall accompany the filing along with adequate supporting information.

NRS 695C.185Approval or denial of claims; payment of claims and interest;
requests for additional information; award of costs and attorney’s fees;
compliance with requirements.

1. Except as otherwise provided in
subsection 2, a health maintenance organization shall approve or deny a claim
relating to a health care plan within 30 days after the health maintenance
organization receives the claim. If the claim is approved, the health
maintenance organization shall pay the claim within 30 days after it is
approved. Except as otherwise provided in this section, if the approved claim
is not paid within that period, the health maintenance organization shall pay
interest on the claim at a rate of interest equal to the prime rate at the
largest bank in Nevada, as ascertained by the Commissioner of Financial
Institutions, on January 1 or July 1, as the case may be, immediately preceding
the date on which the payment was due, plus 6 percent. The interest must be
calculated from 30 days after the date on which the claim is approved until the
date on which the claim is paid.

2. If the health maintenance organization
requires additional information to determine whether to approve or deny the
claim, it shall notify the claimant of its request for the additional information
within 20 days after it receives the claim. The health maintenance organization
shall notify the provider of health care services of all the specific reasons
for the delay in approving or denying the claim. The health maintenance
organization shall approve or deny the claim within 30 days after receiving the
additional information. If the claim is approved, the health maintenance
organization shall pay the claim within 30 days after it receives the
additional information. If the approved claim is not paid within that period,
the health maintenance organization shall pay interest on the claim in the
manner prescribed in subsection 1.

3. A health maintenance organization shall
not request a claimant to resubmit information that the claimant has already
provided to the health maintenance organization, unless the health maintenance
organization provides a legitimate reason for the request and the purpose of
the request is not to delay the payment of the claim, harass the claimant or
discourage the filing of claims.

4. A health maintenance organization shall
not pay only part of a claim that has been approved and is fully payable.

5. A court shall award costs and
reasonable attorney’s fees to the prevailing party in an action brought
pursuant to this section.

6. The payment of interest provided for in
this section for the late payment of an approved claim may be waived only if
the payment was delayed because of an act of God or another cause beyond the
control of the health maintenance organization.

7. The Commissioner may require a health
maintenance organization to provide evidence which demonstrates that the health
maintenance organization has substantially complied with the requirements set
forth in this section, including, without limitation, payment within 30 days of
at least 95 percent of approved claims or at least 90 percent of the total
dollar amount for approved claims.

8. If the Commissioner determines that a
health maintenance organization is not in substantial compliance with the requirements
set forth in this section, the Commissioner may require the health maintenance
organization to pay an administrative fine in an amount to be determined by the
Commissioner. Upon a second or subsequent determination that a health
maintenance organization is not in substantial compliance with the requirements
set forth in this section, the Commissioner may suspend or revoke the
certificate of authority of the health maintenance organization.

NRS 695C.187Schedule for payment of claims: Mandatory inclusion in
arrangements for provision of health care.

1. A health maintenance organization shall
not:

(a) Enter into any contract or agreement, or make
any other arrangements, with a provider for the provision of health care; or

(b) Employ a provider pursuant to a contract, an
agreement or any other arrangement to provide health care,

Ê unless the
contract, agreement or other arrangement specifically provides that the health
maintenance organization and provider agree to the schedule for the payment of
claims set forth in NRS 695C.185.

2. Any contract, agreement or other
arrangement between a health maintenance organization and a provider that is
entered into or renewed on or after October 1, 2001, that does not specifically
include a provision concerning the schedule for the payment of claims as
required by subsection 1 shall be deemed to conform with the requirements of
subsection 1 by operation of law.

NRS 695C.190Commissioner may require submission of information.The Commissioner may require the submission of
whatever relevant information the Commissioner deems necessary in determining
whether to approve or disapprove a filing made pursuant to NRS 695C.170 to 695C.200,
inclusive.

NRS 695C.193Summary of coverage: Contents of disclosure; approval by
Commissioner; regulations. [Effective through December 31, 2013.]

1. The Commissioner shall adopt
regulations which require a health maintenance organization to file with the
Commissioner, for approval by the Commissioner, a disclosure summarizing the
coverage provided by each health care plan offered by the health maintenance
organization. The disclosure must include:

(a) Any significant exception, reduction or
limitation that applies to the plan; and

(b) Any other information,

Ê that the
Commissioner finds necessary to provide for full and fair disclosure of the
provisions of the plan.

2. The disclosure must be written in
language which is easily understood and must include a statement that the
disclosure is a summary of the plan only, and that the evidence of coverage
itself should be read to determine the governing contractual provisions.

3. The Commissioner shall not approve any
proposed disclosure submitted to the Commissioner pursuant to this section
which does not comply with the requirements of this section and the applicable
regulations.

NRS 695C.195Summary of coverage: Copy to be provided before policy issued;
policy not to be offered unless summary approved by Commissioner. [Effective
through December 31, 2013.]A
health maintenance organization shall provide to the group policyholder to whom
it offers a health care plan a copy of the disclosure approved for that plan
pursuant to NRS 695C.193 before the plan is
issued. A health maintenance organization shall not offer a health care plan
unless the disclosure for that plan has been approved by the Commissioner.

NRS 695C.200Approval of forms and schedules. [Effective through December 31,
2013.]The Commissioner shall
within a reasonable period approve any form if the requirements of NRS 695C.170 are met and any schedule of charges if
the requirements of NRS 695C.180 are met. It is
unlawful to issue such form or to use such schedule of charges until approved.
If the Commissioner disapproves such filing, the Commissioner shall notify the
filer. In the notice, the Commissioner shall specify the reasons for
disapproval. A hearing will be granted within 90 days after a request in
writing by the person filing.

(Added to NRS by 1973, 1251)

NRS 695C.200Approval of forms and
schedules. [Effective January 1, 2014.]The
Commissioner shall within a reasonable period approve any form if the
requirements of NRS 695C.170 are met. It is
unlawful to issue such form or to use such schedule of charges until approved.
If the Commissioner disapproves such filing, the Commissioner shall notify the
filer. In the notice, the Commissioner shall specify the reasons for
disapproval. A hearing will be granted within 90 days after a request in
writing by the person filing.

NRS 695C.201Offering policy of health insurance for purposes of establishing
health savings account.A health
maintenance organization may, subject to regulation by the Commissioner, offer
a policy of health insurance that has a high deductible and is in compliance
with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

NRS 695C.203Denying coverage solely because person was victim of domestic
violence prohibited.A health
maintenance organization shall not deny a claim, refuse to issue a policy or
cancel a policy solely because the claim involves an act that constitutes
domestic violence pursuant to NRS 33.018,
or because the person applying for or covered by the policy was the victim of
such an act of domestic violence, regardless of whether the insured or
applicant contributed to any loss or injury.

(a) Deny a claim under a health care plan solely
because the claim involves an injury sustained by an enrollee as a consequence
of being intoxicated or under the influence of a controlled substance.

(b) Cancel participation under a health care plan
solely because an enrollee has made a claim involving an injury sustained by
the enrollee as a consequence of being intoxicated or under the influence of a
controlled substance.

(c) Refuse participation under a health care plan
to an eligible applicant solely because the applicant has made a claim
involving an injury sustained by the applicant as a consequence of being
intoxicated or under the influence of a controlled substance.

2. The provisions of subsection 1 do not
prohibit a health maintenance organization from enforcing a provision included
in a health care plan to:

(a) Deny a claim which involves an injury to
which a contributing cause was the insured’s commission of or attempt to commit
a felony;

(b) Cancel participation under a health care plan
solely because of such a claim; or

(c) Refuse participation under a health care plan
to an eligible applicant solely because of such a claim.

3. The provisions of this section do not
apply to a health maintenance organization under a health care plan that
provides coverage for long-term care or disability income.

(a) Require an enrollee or any member of the
family of the enrollee to take a genetic test;

(b) Require an enrollee to disclose whether the
enrollee or any member of the family of the enrollee has taken a genetic test
or the genetic information of the enrollee or a member of the family of the
enrollee; or

(c) Determine the rates or any other aspect of
the coverage or benefits for health care provided to an enrollee based on:

(1) Whether the enrollee or any member of
the family of the enrollee has taken a genetic test; or

(2) Any genetic information of the
enrollee or any member of the family of the enrollee.

2. As used in this section:

(a) “Genetic information” means any information
that is obtained from a genetic test.

(b) “Genetic test” means a test, including a
laboratory test which uses deoxyribonucleic acid extracted from the cells of a
person or a diagnostic test, to determine the presence of abnormalities or
deficiencies, including carrier status, that:

(1) Are linked to physical or mental
disorders or impairments; or

(2) Indicate a susceptibility to illness,
disease, impairment or any other disorder, whether physical or mental.

1. Every health maintenance organization
shall file with the Commissioner on or before March 1 of each year a report
showing its financial condition on the last day of the preceding calendar year.
The report must be verified by at least two principal officers of the
organization. The organization shall file a copy of the report with the State
Board of Health.

2. The report must be on forms prescribed
by the Commissioner and must include:

(a) A financial statement of the organization,
including its balance sheet and receipts and disbursements for the preceding
calendar year;

(b) Any material changes in the information
submitted pursuant to NRS 695C.070;

(c) The number of persons enrolled during the
year, the number of enrollees as of the end of the year, the number of
enrollments terminated during the year and, if requested by the Commissioner, a
compilation of the reasons for such terminations;

(d) The number and amount of malpractice claims
initiated against the health maintenance organization and any of the providers
used by it during the year broken down into claims with and without form of
legal process, and the disposition, if any, of each such claim, if requested by
the Commissioner;

(e) A summary of information compiled pursuant to
paragraph (c) of subsection 2 of NRS 695C.080 in
such form as required by the State Board of Health; and

(f) Such other information relating to the
performance of the health maintenance organization as is necessary to enable
the Commissioner to carry out his or her duties pursuant to this chapter.

3. Every health maintenance organization
shall file with the Commissioner annually an audited financial statement of the
organization prepared by an independent certified public accountant. The
statement must cover the preceding 12-month period and must be filed with the
Commissioner within 120 days after the end of the organization’s fiscal year.
Upon written request, the Commissioner may grant a 30-day extension.

4. If an organization fails to file timely
the report or financial statement required by this section, it shall pay an
administrative penalty of $100 per day until the report or statement is filed,
except that the total penalty must not exceed $3,000. The Attorney General
shall recover the penalty in the name of the State of Nevada.

5. The Commissioner may grant a reasonable
extension of time for filing the report or financial statement required by this
section, if the request for an extension is submitted in writing and shows good
cause.

1. Every health maintenance organization
shall file with the Commissioner on or before March 1 of each year a report
showing its financial condition on the last day of the preceding calendar year.
The report must be verified by at least two principal officers of the
organization.

2. The report must be on forms prescribed
by the Commissioner and must include:

(a) A financial statement of the organization,
including its balance sheet and receipts and disbursements for the preceding
calendar year;

(b) Any material changes in the information
submitted pursuant to NRS 695C.070;

(c) The number of persons enrolled during the
year, the number of enrollees as of the end of the year, the number of
enrollments terminated during the year and, if requested by the Commissioner, a
compilation of the reasons for such terminations;

(d) The number and amount of malpractice claims
initiated against the health maintenance organization and any of the providers
used by it during the year broken down into claims with and without form of
legal process, and the disposition, if any, of each such claim, if requested by
the Commissioner;

(e) A summary of information compiled pursuant to
paragraph (c) of subsection 1 of NRS 695C.080 in
such form as required by the Commissioner; and

(f) Such other information relating to the
performance of the health maintenance organization as is necessary to enable
the Commissioner to carry out his or her duties pursuant to this chapter.

3. Every health maintenance organization
shall file with the Commissioner annually an audited financial statement of the
organization prepared by an independent certified public accountant. The
statement must cover the preceding 12-month period and must be filed with the
Commissioner within 120 days after the end of the organization’s fiscal year.
Upon written request, the Commissioner may grant a 30-day extension.

4. If an organization fails to file timely
the report or financial statement required by this section, it shall pay an
administrative penalty of $100 per day until the report or statement is filed,
except that the total penalty must not exceed $3,000. The Attorney General
shall recover the penalty in the name of the State of Nevada.

5. The Commissioner may grant a reasonable
extension of time for filing the report or financial statement required by this
section, if the request for an extension is submitted in writing and shows good
cause.

NRS 695C.220Applications, filings and reports open to public inspection.All applications, filings and reports required
under this chapter shall be treated as public documents except as otherwise
provided in this chapter.

(Added to NRS by 1973, 1258)

NRS 695C.230Fees.

1. Every health maintenance organization
subject to this chapter shall pay to the Commissioner the following fees:

(a) For filing an application for a certificate
of authority, $2,450.

(b) For issuance of a certificate of authority,
$250.

(c) For an amendment to a certificate of
authority, $100.

(d) For the renewal of a certificate of
authority, $2,450.

(e) For filing each annual report, $25.

(f) In addition to any other fee or charge, all
applicable fees required pursuant to NRS
680C.110.

2. At the time of filing the annual report
the health maintenance organization shall forward to the department of taxation
the tax and any penalty for nonpayment or delinquent payment of the tax in
accordance with the provisions of chapter 680B
of NRS.

3. All fees paid pursuant to this section
shall be deemed earned when paid and may not be refunded.

NRS 695C.240Information required to be available for inspection.Every health maintenance organization shall
have available for inspection the following information:

1. A current statement of financial
condition including a balance sheet and summary of receipts and disbursements;

2. A description of the organizational
structure and operation of the health maintenance organization and a summary of
any material changes since the issuance of the last report;

3. A description of services and
information as to where and how to secure them; and

4. A clear and understandable description
of the health maintenance organization’s method for resolving enrollee
complaints.

(Added to NRS by 1973, 1252)

NRS 695C.250Open enrollment. [Effective through December 31, 2013.]

1. After a health maintenance organization
has been in operation 24 months, it shall have an annual open enrollment
commensurate with common practices in the area in which it operates.

2. Health maintenance organizations
providing services to a specified group or groups may limit the open enrollment
to all members of such group or groups. “Specified groups” may include:

(a) Employees of one or more specified employers;

(b) Members of one or more specified employee
organizations;

(c) Members of one or more specified
associations; and

(d) Participants in one or more specified group
policies issued by one or more specified insurers if the insurer is involved in
the operation, management or conduct of the health maintenance organization.

1. If a health maintenance organization,
for any final determination of benefits or care, requires an independent
evaluation of the medical or chiropractic care of any person for whom such care
is provided under the evidence of coverage:

(a) The evidence of coverage must include a
procedure for binding arbitration to resolve disputes concerning independent
medical evaluations pursuant to the rules of the American Arbitration
Association; and

(b) Only a physician or chiropractor who is
certified to practice in the same field of practice as the primary treating
physician or chiropractor or who is formally educated in that field may conduct
the independent evaluation.

2. The independent evaluation must include
a physical examination of the patient, unless the patient is deceased, and a
personal review of all X rays and reports prepared by the primary treating
physician or chiropractor. A certified copy of all reports of findings must be
sent to the primary treating physician or chiropractor and the insured person
within 10 working days after the evaluation. If the insured person disagrees
with the finding of the evaluation, the insured person must submit an appeal to
the insurer pursuant to the procedure for binding arbitration set forth in the
evidence of coverage within 30 days after the insured person receives the
finding of the evaluation. Upon its receipt of an appeal, the insurer shall so
notify in writing the primary treating physician or chiropractor.

3. The insurer shall not limit or deny
coverage for care related to a disputed claim while the dispute is in
arbitration, except that, if the insurer prevails in the arbitration, the
primary treating physician or chiropractor may not recover any payment from
either the insurer, insured person or the patient for services that the primary
treating physician or chiropractor provided to the patient after receiving
written notice from the insurer pursuant to subsection 2 concerning the appeal
of the insured person.

1. Except as otherwise provided in NRS 695C.265 and subject to the approval of the
Commissioner, a health maintenance organization may include in any evidence of
coverage issued by the organization a provision which requires an enrollee to
whom the evidence of coverage is issued and the health maintenance organization
to submit for binding arbitration any dispute between the enrollee and the
organization concerning any matter directly or indirectly related to, or
associated with, the evidence of coverage or the health care plan or health
care services of the health maintenance organization. If such a provision is
included in the evidence of coverage:

(a) An enrollee must be given the opportunity to
decline to participate in binding arbitration at the time of his or her
enrollment.

(b) It must clearly state that the health
maintenance organization and an enrollee who has not declined to participate in
binding arbitration agree to forego their right to resolve any such dispute in
a court of law or equity.

2. Except as otherwise provided in
subsection 3, the arbitration must be conducted pursuant to the rules for
commercial arbitration established by the American Arbitration Association. The
health maintenance organization is responsible for any administrative fees and
expenses relating to the arbitration, except that the health maintenance
organization is not responsible for attorney’s fees and fees for expert
witnesses unless those fees are awarded by the arbitrator.

3. If a dispute required to be submitted
to binding arbitration requires an immediate resolution to protect the physical
health of an enrollee, any party to the dispute may waive arbitration and seek
declaratory relief in a court of competent jurisdiction.

4. If a provision described in subsection
1 is included in any evidence of coverage issued by a health maintenance
organization, the provision shall not be deemed unenforceable as an
unreasonable contract of adhesion if the provision is included in compliance
with the provisions of subsection 1.

NRS 695C.270Bond required; waiver.Each
health maintenance organization shall furnish a surety bond in an amount
satisfactory to the Commissioner or deposit with the Commissioner cash or
securities acceptable to the Commissioner in at least the same amount as a
guarantee that the obligations to the enrollees will be performed. The
Commissioner may waive this requirement whenever satisfied that the assets of the
organization and its contracts with insurers, governments, or other
organizations are sufficient to reasonably assure the performance of its
obligations.

(Added to NRS by 1973, 1253)

NRS 695C.275Commissioner to adopt regulations for licensing of provider-sponsored
organizations.

1. To the extent authorized by federal
law, the Commissioner shall adopt regulations for the licensing of
provider-sponsored organizations in this State.

2. As used in this section,
“provider-sponsored organization” has the meaning ascribed to it in 42 U.S.C. §
1395w-25(d).

NRS 695C.280Commissioner authorized to adopt regulations for licensing of
agents or brokers.The
Commissioner may adopt such reasonable regulations as are necessary to provide
for the licensing of agents or brokers. An agent is a person directly or
indirectly associated with a health care plan who engages in solicitation or
enrollment. A broker is a person who is directly involved with the insured in
the manner provided in chapter 683A of NRS.

NRS 695C.290Insurance company may establish or contract with health
maintenance organization.

1. An insurance company licensed in this
State may either directly or through a subsidiary or affiliate organize and
operate a health maintenance organization under the provisions of this chapter.
Notwithstanding any other law which may be inconsistent herewith, any two or
more such insurance companies or subsidiaries or affiliates thereof may jointly
organize and operate a health maintenance organization. The business of
insurance is deemed to include the providing of health care by a health
maintenance organization owned or operated by an insurer or a subsidiary
thereof.

2. An insurer may contract with a health
maintenance organization to provide insurance or similar protection against the
cost of care provided through health maintenance organizations and to provide
coverage in the event of the failure of the health maintenance organization to
meet its obligations. Among other things, under such contracts the insurer may
make benefit payments to health maintenance organizations for health care
services rendered by providers pursuant to the health care plan.

(Added to NRS by 1973, 1254)

NRS 695C.300Prohibited practices.

1. No health maintenance organization or
representative thereof may cause or knowingly permit the use of advertising
which is untrue or misleading, solicitation which is untrue or misleading or
any form of evidence of coverage which is deceptive. For purposes of this
chapter:

(a) A statement or item of information shall be
deemed to be untrue if it does not conform to fact in any respect which is or
may be significant to an enrollee of, or person considering enrollment in, a
health care plan.

(b) A statement or item of information shall be
deemed to be misleading, whether or not it may be literally untrue if, in the
total context in which such statement is made or such item of information is
communicated, such statement or item of information may be reasonably
understood by a reasonable person not possessing special knowledge regarding
health care coverage, as indicating any benefit or advantage or the absence of
any exclusion, limitation or disadvantage of possible significance to an
enrollee of, or person considering enrollment in, a health care plan if such
benefit or advantage or absence of limitation, exclusion or disadvantage does
not in fact exist.

(c) An evidence of coverage shall be deemed to be
deceptive if the evidence of coverage taken as a whole, and with consideration
given to typography and format as well as language, shall be such as to cause a
reasonable person not possessing special knowledge regarding health care plans
and evidences of coverage therefor to expect benefits, services, charges or
other advantages which the evidence of coverage does not provide or which the
health care plan issuing such evidence of coverage does not regularly make
available for enrollees covered under such evidence of coverage.

2. NRS
686A.010 to 686A.310, inclusive,
shall be construed to apply to health maintenance organizations, health care
plans and evidences of coverage except to the extent that the nature of health
maintenance organizations, health care plans and evidences of coverage render
the sections therein clearly inappropriate.

3. An enrollee may not be cancelled or not
renewed except for the failure to pay the charge for such coverage or for cause
as determined in the master contract.

4. No health maintenance organization,
unless licensed as an insurer, may use in its name, contracts, or literature
any of the words “insurance,” “casualty,” “surety,” “mutual” or any other words
descriptive of the insurance, casualty or surety business or deceptively
similar to the name or description of any insurance or surety corporation doing
business in this State.

5. No person not certificated under this
chapter shall use in its name, contracts or literature the phrase “health
maintenance organization” or the initials “HMO.”

(Added to NRS by 1973, 1253)

NRS 695C.310Examinations. [Effective through December 31, 2013.]

1. The Commissioner shall make an
examination of the affairs of any health maintenance organization and providers
with whom such organization has contracts, agreements or other arrangements pursuant
to its health care plan as often as the Commissioner deems it necessary for the
protection of the interests of the people of this State. An examination must be
made not less frequently than once every 3 years.

2. The State Board of Health shall make an
examination concerning the quality of health care services of any health
maintenance organization and providers with whom such organization has
contracts, agreements or other arrangements pursuant to its health care plan as
often as it deems necessary for the protection of the interests of the people
of this State. An examination must be made not less frequently than once every
3 years.

3. Every health maintenance organization
and provider shall submit its books and records relating to the health care
plan to an examination made pursuant to subsection 1 or 2 and in every way
facilitate the examination. Medical records of natural persons and records of
physicians providing service pursuant to a contract to the health maintenance
organization are not subject to such examination, although the records are
subject to subpoena upon a showing of good cause. For the purpose of
examinations, the Commissioner and the State Board of Health may administer
oaths to, and examine the officers and agents of the health maintenance
organization and the principals of such providers concerning their business.

4. The expenses of examinations pursuant
to this section must be assessed against the organization being examined and
remitted to the Commissioner or the State Board of Health, whichever is
appropriate.

5. In lieu of such examination, the
Commissioner may accept the report of an examination made by the insurance
commissioner or the state board of health of another state.

1. The Commissioner shall make an
examination of the affairs of any health maintenance organization and providers
with whom such organization has contracts, agreements or other arrangements
pursuant to its health care plan as often as the Commissioner deems it
necessary for the protection of the interests of the people of this State. An
examination must be made not less frequently than once every 3 years.

2. The Commissioner shall make an
examination concerning the quality of health care services of any health
maintenance organization and providers with whom such organization has
contracts, agreements or other arrangements pursuant to its health care plan as
often as it deems necessary for the protection of the interests of the people
of this State. An examination must be made not less frequently than once every 3
years.

3. Every health maintenance organization
and provider shall submit its books and records relating to the health care
plan to an examination made pursuant to subsection 1 or 2 and in every way
facilitate the examination. Medical records of natural persons and records of
physicians providing service pursuant to a contract to the health maintenance
organization are not subject to such examination, although the records are
subject to subpoena upon a showing of good cause. For the purpose of examinations,
the Commissioner may administer oaths to, and examine the officers and agents
of the health maintenance organization and the principals of such providers
concerning their business.

4. The expenses of examinations pursuant
to this section must be assessed against the organization being examined and
remitted to the Commissioner.

5. In lieu of such examination, the
Commissioner may accept the report of an examination made by the insurance
commissioner or the state board of health of another state.

1. For the purpose of determining its
financial condition, fulfillment of its contractual obligations and compliance
with law, the Commissioner shall, as often as the Commissioner deems advisable,
examine the affairs, transactions, accounts, records and assets of a health
maintenance organization and of any person as to any matter relevant to the
financial affairs of the health maintenance organization or to the examination.
Except as otherwise provided in this Code, the Commissioner shall examine each
health maintenance organization at least once every 3 years.

2. The Commissioner shall examine each
health maintenance organization applying for an initial certificate of
authority.

3. In lieu of making his or her own
examination, the Commissioner may, in the discretion of the Commissioner, accept
a full report of the last recent examination of a foreign or alien health
maintenance organization, certified to by the supervisory officer of insurance
of another state.

4. To the extent that it is practical, the
examination of a foreign or alien health maintenance organization must be made
in cooperation with the insurance supervisory officers of other states in which
the organization transacts business.

NRS 695C.313Financial examination: Procedure; appointment of examiner;
maintenance and use of records; penalty for obstruction or interference.

1. If the Commissioner determines to
examine a health maintenance organization pursuant to NRS
695C.311, the Commissioner shall designate one or more examiners and
instruct them as to the scope of the examination. The examiner shall, upon
demand, exhibit his or her official credentials to the health maintenance
organization being examined.

2. The Commissioner shall conduct each
examination in an expeditious, fair and impartial manner.

3. The Commissioner, or the examiner if
the examiner is authorized in writing by the Commissioner, may administer oaths
and examine under oath any person concerning any matter relevant to the
examination.

4. Every health maintenance organization
and its officers, attorneys, employees, agents and representatives shall make
available to the Commissioner or the examiners of the Commissioner the
accounts, records, documents, files, information, assets and matters of the
health maintenance organization in his or her possession or control relating to
the subject of the examination and shall facilitate the examination.

5. If the Commissioner or examiner finds
any accounts or records to be inadequate or inadequately kept or posted, he or
she shall so notify the health maintenance organization and give the health
maintenance organization a reasonable opportunity to reconstruct, rewrite, post
or balance the account or record. If the health maintenance organization fails
to maintain, complete or correct the records or accounting after the
Commissioner or examiner has given the health maintenance organization written
notice and a reasonable opportunity to do so, the Commissioner may employ
experts to reconstruct, rewrite, post or balance the account or record at the
expense of the health maintenance organization being examined.

6. The Commissioner or an examiner shall
not remove any record, account, document, file or other property of the health
maintenance organization being examined from the office or place of business of
the health maintenance organization unless the Commissioner or examiner has the
written consent of an officer of the health maintenance organization before the
removal or pursuant to an order of court. This provision does not prohibit the
Commissioner or examiner from making or removing copies or abstracts of a
record, account, document or file.

7. Any person who, without just cause,
refuses to be examined under oath or who willfully obstructs or interferes with
an examiner in the exercise of his or her authority is guilty of a misdemeanor.

1. The health maintenance organization
being examined shall pay the expense of an examination. The expenses to be paid
include only the reasonable and proper travel and lodging expenses of the
Commissioner and the examiners and assistants of the Commissioner, including
expert assistance, reasonable compensation to the examiners and assistants and
incidental expenses as necessarily incurred in the examination. The
Commissioner shall consider the scales and limitations recommended by the
National Association of Insurance Commissioners regarding the expense and
compensation for an examination.

2. The health maintenance organization
shall promptly pay to the Commissioner the expenses of the examination upon
presentation by the Commissioner of a reasonably detailed written statement thereof.

NRS 695C.320Rehabilitation, liquidation or conservation.Any rehabilitation, liquidation or
conservation of a health maintenance organization shall be deemed to be the
rehabilitation, liquidation or conservation of an insurance company and shall
be conducted under the supervision of the Commissioner pursuant to the law
governing the rehabilitation, liquidation, or conservation of insurance
companies.

(Added to NRS by 1973, 1256)

NRS 695C.325Authorization to offer health care plan to small employer for
purpose of establishing medical savings accounts.A
health maintenance organization may offer to a small employer who has not less
than 2 and not more than 50 employees, a health care plan that has a high
deductible and that is in compliance with 26 U.S.C. § 220 for the purposes of
establishing medical savings accounts for any person insured by the health care
plan.

1. The Commissioner may suspend or revoke
any certificate of authority issued to a health maintenance organization
pursuant to the provisions of this chapter if the Commissioner finds that any
of the following conditions exist:

(a) The health maintenance organization is
operating significantly in contravention of its basic organizational document,
its health care plan or in a manner contrary to that described in and
reasonably inferred from any other information submitted pursuant to NRS 695C.060, 695C.070
and 695C.140, unless any amendments to those
submissions have been filed with and approved by the Commissioner;

(b) The health maintenance organization issues
evidence of coverage or uses a schedule of charges for health care services
which do not comply with the requirements of NRS
695C.1691 to 695C.200, inclusive, or 695C.207;

(c) The health care plan does not furnish
comprehensive health care services as provided for in NRS
695C.060;

(d) The State Board of Health certifies to the
Commissioner that the health maintenance organization:

(1) Does not meet the requirements of
subsection 2 of NRS 695C.080; or

(2) Is unable to fulfill its obligations
to furnish health care services as required under its health care plan;

(e) The health maintenance organization is no
longer financially responsible and may reasonably be expected to be unable to
meet its obligations to enrollees or prospective enrollees;

(f) The health maintenance organization has
failed to put into effect a mechanism affording the enrollees an opportunity to
participate in matters relating to the content of programs pursuant to NRS 695C.110;

(g) The health maintenance organization has
failed to put into effect the system required by NRS
695C.260 for:

(1) Resolving complaints in a manner
reasonably to dispose of valid complaints; and

(2) Conducting external reviews of adverse
determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

(h) The health maintenance organization or any
person on its behalf has advertised or merchandised its services in an untrue,
misrepresentative, misleading, deceptive or unfair manner;

(i) The continued operation of the health
maintenance organization would be hazardous to its enrollees;

(j) The health maintenance organization fails to
provide the coverage required by NRS 695C.1691;
or

(k) The health maintenance organization has
otherwise failed to comply substantially with the provisions of this chapter.

2. A certificate of authority must be
suspended or revoked only after compliance with the requirements of NRS 695C.340.

3. If the certificate of authority of a
health maintenance organization is suspended, the health maintenance
organization shall not, during the period of that suspension, enroll any
additional groups or new individual contracts, unless those groups or persons
were contracted for before the date of suspension.

4. If the certificate of authority of a
health maintenance organization is revoked, the organization shall proceed,
immediately following the effective date of the order of revocation, to wind up
its affairs and shall conduct no further business except as may be essential to
the orderly conclusion of the affairs of the organization. It shall engage in
no further advertising or solicitation of any kind. The Commissioner may, by
written order, permit such further operation of the organization as the
Commissioner may find to be in the best interest of enrollees to the end that
enrollees are afforded the greatest practical opportunity to obtain continuing
coverage for health care.

1. The Commissioner may suspend or revoke
any certificate of authority issued to a health maintenance organization
pursuant to the provisions of this chapter if the Commissioner finds that any
of the following conditions exist:

(a) The health maintenance organization is
operating significantly in contravention of its basic organizational document,
its health care plan or in a manner contrary to that described in and
reasonably inferred from any other information submitted pursuant to NRS 695C.060, 695C.070
and 695C.140, unless any amendments to those
submissions have been filed with and approved by the Commissioner;

(b) The health maintenance organization issues
evidence of coverage or uses a schedule of charges for health care services
which do not comply with the requirements of NRS
695C.1691 to 695C.200, inclusive, or 695C.207;

(c) The health care plan does not furnish comprehensive
health care services as provided for in NRS 695C.060;

(d) The Commissioner certifies that the health
maintenance organization:

(1) Does not meet the requirements of
subsection 1 of NRS 695C.080; or

(2) Is unable to fulfill its obligations
to furnish health care services as required under its health care plan;

(e) The health maintenance organization is no
longer financially responsible and may reasonably be expected to be unable to
meet its obligations to enrollees or prospective enrollees;

(f) The health maintenance organization has
failed to put into effect a mechanism affording the enrollees an opportunity to
participate in matters relating to the content of programs pursuant to NRS 695C.110;

(g) The health maintenance organization has
failed to put into effect the system required by NRS
695C.260 for:

(1) Resolving complaints in a manner
reasonably to dispose of valid complaints; and

(2) Conducting external reviews of adverse
determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

(h) The health maintenance organization or any
person on its behalf has advertised or merchandised its services in an untrue,
misrepresentative, misleading, deceptive or unfair manner;

(i) The continued operation of the health
maintenance organization would be hazardous to its enrollees;

(j) The health maintenance organization fails to
provide the coverage required by NRS 695C.1691;
or

(k) The health maintenance organization has
otherwise failed to comply substantially with the provisions of this chapter.

2. A certificate of authority must be
suspended or revoked only after compliance with the requirements of NRS 695C.340.

3. If the certificate of authority of a
health maintenance organization is suspended, the health maintenance
organization shall not, during the period of that suspension, enroll any
additional groups or new individual contracts, unless those groups or persons
were contracted for before the date of suspension.

4. If the certificate of authority of a
health maintenance organization is revoked, the organization shall proceed,
immediately following the effective date of the order of revocation, to wind up
its affairs and shall conduct no further business except as may be essential to
the orderly conclusion of the affairs of the organization. It shall engage in
no further advertising or solicitation of any kind. The Commissioner may, by
written order, permit such further operation of the organization as the
Commissioner may find to be in the best interest of enrollees to the end that
enrollees are afforded the greatest practical opportunity to obtain continuing
coverage for health care.

1. When the Commissioner has cause to
believe that grounds for the denial of an application for a certificate of
authority exist, or that grounds for the suspension or revocation of a
certificate of authority exist, the Commissioner shall notify the health
maintenance organization and the State Board of Health in writing specifically
stating the grounds for denial, suspension or revocation and fixing a time at
least 30 days thereafter for a hearing on the matter.

2. The State Board of Health or its delegated
representative shall be in attendance at the hearing and shall participate in
the proceedings. The recommendation and findings of the State Board of Health
with respect to matters relating to the quality of health maintenance services
provided in connection with any decision regarding denial, suspension or
revocation of a certificate of authority are conclusive and binding upon the
Commissioner. After the hearing, or upon the failure of the health maintenance
organization to appear at the hearing, the Commissioner shall take action as is
deemed advisable on written findings which must be mailed to the health
maintenance organization with a copy thereof to the State Board of Health. The
action of the Commissioner and the recommendation and findings of the State
Board of Health are subject to review by the First Judicial District Court of
the State of Nevada in and for Carson City. The court may, in disposing of the
issue before it, modify, affirm or reverse the order of the Commissioner in
whole or in part.

1. When the Commissioner has cause to
believe that grounds for the denial of an application for a certificate of
authority exist, or that grounds for the suspension or revocation of a
certificate of authority exist, the Commissioner shall notify the health
maintenance organization in writing specifically stating the grounds for
denial, suspension or revocation and fixing a time at least 30 days thereafter
for a hearing on the matter.

2. After the hearing, or upon the failure
of the health maintenance organization to appear at the hearing, the
Commissioner shall take action as is deemed advisable on written findings which
must be mailed to the health maintenance organization. The action of the
Commissioner is subject to review by the First Judicial District Court of the
State of Nevada in and for Carson City. The court may, in disposing of the
issue before it, modify, affirm or reverse the order of the Commissioner in
whole or in part.

1. The Commissioner may, in lieu of
suspension or revocation of a certificate of authority under NRS 695C.330, levy an administrative penalty in an
amount not more than $2,500 for each act or violation, if reasonable notice in
writing is given of the intent to levy the penalty.

2. Any person who violates the provisions
of this chapter is guilty of a misdemeanor.

3. If the Commissioner or the State Board
of Health for any reason have cause to believe that any violation of this
chapter has occurred or is threatened, the Commissioner or the State Board of
Health may give notice to the health maintenance organization and to the
representatives, or other persons who appear to be involved in the suspected
violation, to arrange a conference with the alleged violators or their
authorized representatives to attempt to determine the facts relating to the
suspected violation, and, if it appears that any violation has occurred or is
threatened, to arrive at an adequate and effective means of correcting or
preventing the violation.

4. The proceedings conducted pursuant to the
provisions of subsection 3 must not be governed by any formal procedural
requirements, and may be conducted in such manner as the Commissioner or the
State Board of Health may deem appropriate under the circumstances.

5. The Commissioner may issue an order
directing a health maintenance organization or a representative of a health
maintenance organization to cease and desist from engaging in any act or
practice in violation of the provisions of this chapter.

6. Within 30 days after service of the order
to cease and desist, the respondent may request a hearing on the question of
whether acts or practices in violation of this chapter have occurred. The
hearing must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must
be available as provided therein.

7. In the case of any violation of the
provisions of this chapter, if the Commissioner elects not to issue a cease and
desist order, or in the event of noncompliance with a cease and desist order
issued pursuant to subsection 5, the Commissioner may institute a proceeding to
obtain injunctive relief, or seek other appropriate relief in the district
court of the judicial district of the county in which the violator resides.

1. The Commissioner may, in lieu of
suspension or revocation of a certificate of authority under NRS 695C.330, levy an administrative penalty in an
amount not more than $2,500 for each act or violation, if reasonable notice in
writing is given of the intent to levy the penalty.

2. Any person who violates the provisions
of this chapter is guilty of a misdemeanor.

3. If the Commissioner for any reason has
cause to believe that any violation of this chapter has occurred or is
threatened, the Commissioner may give notice to the health maintenance
organization and to the representatives, or other persons who appear to be
involved in the suspected violation, to arrange a conference with the alleged
violators or their authorized representatives to attempt to determine the facts
relating to the suspected violation, and, if it appears that any violation has
occurred or is threatened, to arrive at an adequate and effective means of correcting
or preventing the violation.

4. The proceedings conducted pursuant to
the provisions of subsection 3 must not be governed by any formal procedural
requirements, and may be conducted in such manner as the Commissioner may deem
appropriate under the circumstances.

5. The Commissioner may issue an order
directing a health maintenance organization or a representative of a health
maintenance organization to cease and desist from engaging in any act or
practice in violation of the provisions of this chapter.

6. Within 30 days after service of the
order to cease and desist, the respondent may request a hearing on the question
of whether acts or practices in violation of this chapter have occurred. The
hearing must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must
be available as provided therein.

7. In the case of any violation of the
provisions of this chapter, if the Commissioner elects not to issue a cease and
desist order, or in the event of noncompliance with a cease and desist order
issued pursuant to subsection 5, the Commissioner may institute a proceeding to
obtain injunctive relief, or seek other appropriate relief in the district
court of the judicial district of the county in which the violator resides.